I teach Huang Di Nei Jing at the Pacific College of Oriental Medicine in New York. As part of that class I try to present students with an overview of what this classical text presents to readers. In addition, I try to get them to look at the text for what it says, and, by doing so, question how we practice medicine today. I also encourage students to think about how we read into the Nei Jing things we want to see based on modern biases (trust me, there are a lot!). I find that looking at the broader history of culture, and the history of medicine helps in this endeavor.
So, this week I assigned reading that lead to an interesting and challenging discussion. The reading we discussed was a fantastic article by Dr. Volker Scheid that traced the idea of zheng/pattern (證) from roughly the Song dynasty to the present. One of the ideas highlighted in that article and our discussion was the question of intuition in medicine (intuition as an aspect of Yi 意 – conception, subjectivity, etc…). In some periods of Chinese medicine, this aspect of subjectivity becomes a core focus of how physicians define their own practice and their ability to arrive at appropriate diagnosis and treatment.
To make the content of our discussion shorter for the purpose of this blog, the question of intuition and subjectivity came up. One of the students in class said something to me that struck me as particularly odd. They said that they thought intuition played a smaller role in the prescription of herbal medicine, but a large role in acupuncture (I won’t try to unpack the herbal medicine question here). I was also told that in their educational experience some clinical supervisors either themselves chose points, or encouraged students to choose points based on their intuition.
There is a fantastic quote in Dr. Scheid’s article that really rang true for me. It is from an 18th century Japanese physician, Yoshimasu Todo:
“Once the notion that medicine is about yì had emerged, it became over time a deceptive strategy and finally an excuse [for bad practice]. In my opinion, if progress on the path of medicine depends only on yì, then why does one first need to study books in order to learn one’s trade but later rely on [yì]? How truly absurd and ridiculous. How could this be called a path [of learning]? [Is it not rather the other way around], namely that proceeding from established strategies on the path of medicine prevents one from going astray? Clearly that is how it is.”
One of the beautiful things about the way I practice and teach acupuncture is that it is based on a very logical and clear set of theories that lead from patient complaint to potentially effective acupuncture points. Here is a diagram from the book I wrote together with Dr. Ross that looks at some aspect of this.
If we break down patient complaints, and know enough about how Chinese medicine defines channel locations, signs and symptoms, Zang-Fu theory, etc… then choosing potentially effective acupuncture points is clear and scientific. Why scientific? Because it is based on rational laws that are derived from clinical observation and experience. Because it is based on the same it can be taught to others so that with practice my students can do exactly what I do.
But then, we still only have ‘potentially’ effective points. I’m usually not content guessing which point will be good in any given clinical encounter. I like to hedge my bets by asking the point if it will be effective before actually needling. In my experience, in almost every clinical encounter somehow points will talk to us. How so? Well, here are a few ‘listening’ strategies that I employ.
- Point Sensitivity: In many cases points become sensitive to touch. This is because the body will set up areas of reflex pain (i.e., areas of mini-stagnation) based on the area of disease. So, palpate patients.
- Tissue Change: Areas along the channels will experience tissue change based on pathology. This can be palpable heat, cold, areas of depression, areas of hardness, nodules, and other finding. These tissue changes will alert us to not only effective treatment points, but also factor into diagnosis and choice of appropriate therapy (e.g., a point will tell you, based on feel, if moxa is appropriate, or needling is appropriate). Did I mention palpate patients?
- Visible Changes: Points and areas of the body will also show visible signs of reactivity in the form of discoloration, visible skin texture changes, spider nevi, or other types of venous congestion. This is particularly important when choosing points for bloodletting therapy.
- Testing Points with the Pulse: This is a technique from Japanese acupuncture that I introduced into Tung’s acupuncture. Pulse images will normalize when palpating effective treatment points at the same time palpating the pulse. Likewise, even Tung’s points will normalize Hara (abdomen) diagnosis findings.
I’m sure there are a lot of other methods I’m simply not thinking of off the top of my head. And I’d like to be clear – I don’t believe there is no room in acupuncture for intuition or subjectivity. I just think it’s a smaller role than many assume, and it is more often used as a crutch and excuse for students or practitioners who don’t really know the basics.