Offering Complex Patients a Simple Piece of Heaven
Did you know?
For the cost of 5 articles (students) or 10 articles (practitioners) you can buy a year's access to the entire Journal of Chinese Medicine article archive.
The medical complexity of some modern-day patients can overwhelm any attempts at either Chinese medical pattern discrimination or Japanese palpation-based assessment. Such cases can leave the practitioner bewildered and unable to devise a coherent treatment plan. The philosophical underpinnings of Chinese medicine would suggest such complexity be handled with simplicity. This paper offers a simple yet adaptable treatment strategy for complex patients based on the Early Heaven – Later Heaven framework.
Central to Chinese medicine and its philosophical underpinnings is the notion that, when things become extreme, they change into their opposite. King Wen’s Later Heaven 64 hexagram sequence in the I Ching (Book of Changes) embodies this principle. Medical implications from the hexagram 23 (Splitting Apart) to 24 (Return) transition is just one example recently discussed by Lonny Jarrett in his book, Nourishing Destiny (*meaningless without discussion). These principles can also be translated into lessons for appropriate action. How many passages of the Tao Te Ching, for example, instruct us to approach the hard with softness (or some such variation on that theme)?
Many patients we see in modern practice present us with overwhelmingly complicated medical scenarios. There are days in my practice when I just long for a patient with a simple ‘back sprain’. A more typical patient coming to my clinic for acupuncture might present with a list of complaints such as insomnia, anxiety, night sweats, widespread body pain, dizziness, fatigue, numbness in various places, headaches, temporomandibular joint disorder, allergies, shortness of breath, urinary incontinence, diabetes, hypothyroidism, hypertension, a surgical history that includes cholecystectomy, complete hysterectomy and double mastectomy, a complex regimen of multiple medications a pulse that exhibits both deficiency and excess and a highly complicated tongue presentation. Practising Chinese medicine, I must do my best to understand the whole picture through the various lenses we have: eight principle patterns, five phase theory, zangfu patterns etc. Pattern discrimination with a patient like this is daunting, overwhelming and intimidating all at once. Especially when, to complicate matters, the patient in their multi-symptomatic and medication-induced confusion, just cannot seem to give me consistent or informative answers to the finer questions I like to ask (‘are you dizzy when lying down or standing up?’, ’do you have trouble getting to sleep or do you wake frequently?’ etc.)
Part of my inner voice hears Bob Flaws at a recent seminar I attended expounding on the theme of mutual engenderment and the consequent need to treat every presenting pattern simultaneously (the basis for the exceptionally large number of herbs in most Blue Poppy prepared formulas). But my instinct feels repeatedly repulsed as I attempt to harness my intellectual skills of pattern discrimination to catch every pattern in the net. The situation is bewildering, noisy, messy and unsatisfactory. I (*also?) practise Kiiko Matsumoto’s palpatory style of acupuncture and this has often been a godsend in such cases because it gives me the luxury of shutting down all my cerebral ‘noise’ and treating what presents in terms of palpated reactions on the patient’s body. Unfortunately, in some of these cases, even that approach yields too much noise. Early on in my practice, if I was not careful, I would end up peppering the patient with too many needles. After shutting the treatment room door behind me, I would stop and ask myself, ‘what have I done?’
It wasn’t long after I started my practice (*timescale odd) that, with such cases, I would throw up my hands before devising my treatment plan, look to the heavens, and ask, ‘what do you want me to do?’
And the heavens replied with an answer for the appropriate treatment of such patients and I have found great satisfaction in the result. My inspiration for treating complex patients like this came from the I Ching and Tao Te Ching themes mentioned above. Surely, I found myself thinking over and over again, such medical complexity must be approached with therapeutic simplicity. As I plumbed my knowledge of Chinese medicine for an answer, a treatment strategy that both embodied simplicity, yet had something therapeutically profound to offer such a ‘sick’ patient, came to mind. The dual concepts of Early and Later Heaven Essence form its basis. What could be more appropriate for such a patient than to engage their Early Heaven Essence (Xian Tian Zhi Jing) and simultaneously stimulate optimal generation of Later Heaven Essence (Hou Tian Zhi Jing). Aside from the integrity and appealing elegance that resonates with such an approach, it seemed to me that such a strategy also offered the patient a connection between their past and their present (Early and Later Heaven), a contiguous thread that could be of tremendous importance to someone bogged down in such a quagmire of illness.
And so, I arrived at a core treatment formula that includes a Kidney point (to access the patient’s Early Heaven Essence) and Zusanli ST-36 (to stimulate the patient’s optimal production of Later Heaven Essence). I might choose from Zhaohai KID-6, Taixi KID-3 or Yongquan KID-1 depending on my understanding of the patient. Based on Japanese acupuncture protocols, Zhubin KID-9 is also often considered when the patient is highly medicated. And a five element practitioner might focus on Fuliu KID-7. To round out the core formula with an upper limb point, I typically add Lieque LU-7 (which also complements the ‘grain’ aspect of Later Heaven Qi (*mention ST-36) with the ‘air’ aspect of Later Heaven Qi and provides an option for a Conception Vessel treatment if Zhaohai KID-6 was chosen as the Kidney point). Zhongwan REN-12 is added as the final part of the core formula. In a recent workshop I attended, Kiiko Mastumoto reminded us that the twelve channel circuit begins at Zhongwan REN-12 and not Zhongfu LU-1 as commonly suggested. This comes from the Ling Shu and can also be seen in any acupuncture text which shows Zhongwan REN-12 as the starting point for the Lung chanel. My logic here is that Zhongwan REN-12 is a logical place to ‘prime’ or ‘kick start’ the full twelve channel circulation in a sick patient.
I very often conclude the treatment with a brief stimulation of Dazhui DU-14 with the intent to stimulate the Governing vessel, bring some clear yang qi to a very murky situation and complete a general sense of yin-yang front-back balance to the overall treatment.
In total, the simple base treatment I often give such medically complicated patients when my discrimination skills feel fully overwhelmed consists of:
a Kidney channel point (based on patient specifics and practitioner orientation),
Zhongwan REN-12, and often
Within this formula, there is plenty of room to vary the unilateral, bilateral, contralateral and ipsilateral options based on an understanding of the patient. For example a female patient might receive right Lieque LU-7 and left Zhaohai KID-6 to stimulate the Conception Vessel with right Taixi KID-3 to access yuan qi as well as Zusanli ST-36 bilaterally and Zhongwan REN-12.
This simple four or five-point formula with potentially as few as five needles, offers the patient access to both Early and Later Heaven Essence while also kick-starting a full twelve channel circulation during the treatment session. What more could I possibly ask that acupuncture offer such chronically ill, complicated and over medicated patients?
As a final addition, I may add one or two points to the protocol to specifically target the patient’s most pressing symptom at the time of treatment. I tell the patient from the outset that since they have so many different things going on, my main priority is to work below the symptoms at a level that will give their body some strength to deal with the whole situation. I tell them that trying to address all their varied symptoms from week to week would amount to a wild goose chase, but that in addition to the core treatment, I can address what is the most pressing symptom during each visit.
Over several years of offering this approach, my experience has been very favourable. Most patients report feeling much better after such a treatment. In fact, it often stuns me how many of their varied symptoms improve with such a simple approach. And as I offer this treatment, once again, I hear Bob Flaws telling me at that same seminar, ‘a beginner uses many formulas, a master uses few.’ This approach was certainly exemplified by Miriam Lee’s famous one-size-fits-all SP-6 (Sanyinjiao), ST-36 (Zusanli), LI-4 (Hegu), LI-11 (Quchi), LU-7 (Lieque) strategy (*delete sentence). Not that I am a master or will ever be one; I would never make such a presumption. But my quest for simplicity when confronted with overwhelming complexity tells me my clinical wisdom is shifting in the right direction.
Daniel Schulman graduated from the New England School of Acupuncture in 1999 and has been in private practice in Charlottetown, Prince Edward Island, Canada ever since.
* Orders shipped outside of Europe are eligible for VAT relief and will not be charged VAT.