June 7, 2010

Combining Chinese Herbal Formulas, pt. 1: Reynolds’ First Maxim

If there’s one lesson that everyone learns very quickly once they start treating, it’s that modern patients have complex conditions that don’t readily fit into any of the ready-made boxes we have formed for them, whether from a Classical or TCM standpoint. Patients usually have multiple ailments all stacked on top of each other like a messy garage. Like said messy garage, some things are new, some things have been there a long time, some things no one knows where they came from, and sometimes there are even animals and insects hiding out. All of this is what you have on your plate the second a patient comes into your clinic, sits in front of you and says “my shoulder hurts” (the ubiquitous ailment).

We’re all familiar with that momentary surge of apprehension (or outright panic) that wells up in this situation, especially if the patient has a Western diagnosis with a scary name like cancer, Lyme disease, autism, etc. However our tools are absolutely equal to the task of even the most complex cases. As the Ling Shu says, “Thorns can be pulled out, even those embedded for a long time; stains can be cleaned, even old ones; knots can be undone, even those formed long ago; accumulation can be demolished, though it be very old.”

One of the keys to successfully treating complex conditions is to be able to competently combine already-extant herbal formulas into a single prescription to match the situation. More accurately, the trick is to use the best tools to perform the right actions at the right times continuously (a subject which I will discuss further in my column on Friday). Over the next few weeks I hope to help those having trouble with formula combining to get a better grasp on it.

So, let’s begin at the beginning.

Reynolds’ First Maxim

There’s one thing that trips up everyone at the beginning (and some folks forever), which is the basis of what I like to call “Reynolds’ First Maxim.” The joke is that I only answer any question my students ask with about five possible responses, so to save time they can be referred to by number. What typically happens is this: a student gets a patient in clinic who comes in with three different “named” diseases like, say, Crohn’s disease, PCOS, and Fibromyalgia. The student gets intimidated, panics, runs through their mandatory battery of questions, needles the Four Gates per supervisor, then calls or emails me with “I have a Crohn’s disease patient. Can you tell me what formula is for that?”

To this I always have the same response:

What are the symptoms?

It’s very easy to get bogged down in the details of what someone else has decided about a patient, whether they are from your side of the healthcare fence or not. We have to be very very careful to not slap names on conditions and try to treat those, whether we are discussing biomedical diagnoses or Zang Fu patterns. Any case that you see is only going to open up to you (like the proverbial flower to the bee) once you start diagnosing, which means using the tools at your disposal to find out what’s really going and making your own judgment. Remember the Four Pillars of Diagnosis? Asking, Looking, Listening, and Touching. These are absolute necessities for any type of case, no matter how easy or difficult. It’s no good just saying “I’m watching this patient for Bob who is on vacation and he says she has Spleen Qi Deficiency so I’m gonna give her Si Jun Zi Tang.” That absolutely won’t cut it. It also won’t do to say “Well, I saw on the internet a study that says Huang Qi is good for autoimmune conditions and since Crohn’s is an autoimmune condition I’ll give her that Huang Qi-based patent we have in the pharmacy.”

You absolutely must do your due diagnostic diligence and find out specifically and systemically what is going on with the patient. Then you can begin to make choices. As long as you are confined to throwing herbs and points at a name, you won’t see results and the patient won’t be sticking with you for very long.

The next step is to make sure that you are using a diagnostic model that is going to steer you in the right direction and provide useful information about what to actually do about the problem, which is what we will discuss next week. For now, remember that the first thing you absolutely must do is find out what is going on with the patient in order to have something to work with.

In other words, what are the symptoms?

Combining Chinese Herbal Formulas, pt. 1: Reynolds’ First Maxim