Common Sense Questioning
Common Sense Questioning
Published on March 9th, 2010 @ 09:15:00 am , using 908 words, 1007 views
by Bob Flaws
If people know you're a doctor, they're always asking you in social settings how to treat this or that ailment they or a loved one is suffering from. If people know you're a famous doctor, albeit of Chinese medicine, these kinds of requests are ubiquitous and never-ending. So I wasn't particularly surprised this weekend when a woman I was chatting with at a social gathering asked me for a recommendation for a Blue Poppy formula. As always in such situations, I strongly advised that she see a professional practitioner of Chinese medicine who could do a proper in-take and diagnosis. However, the woman told me she had been to see many practitioners of acupuncture/Chinese medicine over the years as well as Western MDs, DCs, and NDs, all to no avail.
...
When I asked the woman, who was in her mid to late 40s, what the problem was, she told me that her left foot and lower leg had been swollen since she was in her late teens. The onset of the swelling had been gradual and insidious and was definitely not associated with any trauma, disease, or gynecological event. I asked the woman if she had pitting edema, but, since she didn't know what that is, I asked her to show me the foot. When she took off her sock, the swelling was quite obvious. However, on pressure, there was no pitting. The skin on the affected foot was not discolored in any way and the skin was not abnormal in its texture. Nor were there any venous abnormalities or engorgement. In addition, the foot was normal in anatomical shape and temperature, neither hot nor cold to the touch. I asked the woman about her right foot and she told me that, although it could be a little swollen from time to time, it was basically normal. I asked to see that foot, and, taking off her right sock, sure enough, the foot looked absolutely normal. Next I asked her if she felt any discomfort or pain in the affected foot or any other abnormal sensations. The answer was no. There was no pain in the joints, no numbness, no hot or cold feelings, and no inhibition in movement or function.
At this point the woman told me that every acupuncturist/practitioner of Chinese medicine had told her "it was her kidneys." So I asked her a few questions about standard kidney vacuity symptoms. All were negative as I expected: no low back pain, no sore knees, no urinary problems, no tinnitus or dizziness. I then told her that I did not think her problem was physiologic, i.e., a problem with the function of any of her internal organs. If it were, the swelling would be bilateral. So I thought it was an anatomical problem. Upon making this suggestion, the woman said that her mother and her mother's four sisters (from a large eastern European family) all had exactly the same one-sided foot and ankle edema as did her grandmother and her two great aunts. I asked about her mother's health. The woman said her Mom was 80 and in great health, that her mother's swollen foot was not associated with any kind of disease or debility. This confirmed for me that the woman's problem was 1) an inherited genetic abnormality in the veins in her left leg, 2) medically insignificant, and 3) was not going to respond to any treatment, whether with "acupuncture," massage, or internal medicine, Chinese, Western, or Hottentot.
All this took less than 15 minutes to suss out using simple common sense. So it was depressing to me that several acupuncturists/practitioners of Chinese medicine had failed to ask the few basic questions in order to come to the same obvious conclusions. Instead, they had all immediately jumped to the unwarranted conclusion that lower extremity edema meant there was kidney vacuity. In other words, they failed to take into account that the edema was one-sided, was not associated with any discomfort or debility, and was a familial trait spanning at least three generations, all female. Because of these knee-jerk reactions, the woman had spent untold amounts on unnecessary treatments and "herbs" as well as untold hours, days, months, and years of unnecessary worry and anxiety. Rather than feeling disappointed when I told her there was nothing to be done about her swollen foot, the woman said she was profoundly relieved to know she could stop worrying about it.
Nothing that I asked or did in this "examination" was based on some esoteric knowledge of Chinese medicine only I have access to. All my questions were based on simple common sense, one question leading to the next, making sure that I really did understand the "patient's" situation, the whole situation including the family history. While the woman left this encounter feeling considerable relief, I left it feeling more than a little frustrated over my colleagues' lack of basic perspicacity. If my questions and conclusions had been based on some higher level of Chinese medical knowledge only knowable from reading Chinese, I would not have felt so discomfited, but that simply was not the case. In the practice of medicine, it is vitally important not to allow oneself the laziness of knee-jerk reactions. We must all be sure to question our patients thoroughly so that we really do understand their cases and that we don't jump to unwarranted conclusions.
Copyright Blue Poppy Press, 2010. All Rights reserved.
Permalink6 comments
YES!This is a great post Bob! Its vital that we always remember that, first and foremost, we are providing health care. And while TCM may be our approach and/or specialty, common sense should always be our starting point.
I recently did a work-up on a woman complaining of migraines that she'd had on and off since childhood. Like the woman you described, she had been to various practitioners who had come up with various "diagnoses" and had given her enough herbal medicine and supplements to make her rattle, with zero success.
Upon further questioning, I discovered gaps in her experience of migraines. They stopped when she became a teenager, then started up again recently when she moved to Boulder. Upon further questioning about her western medical care on this issue, I discovered that an optometrist had diagnosed her as having a genetic condition that made her more sensitive to light than the average joe, which also pre-disposed her to this type of migraine. The last piece of the puzzle came when she told me (not as part of the intake, but conversationally) that she had recently stopped wearing make-up. She had done this, somewhat self-consciously, to try and fit in with our local Boulder/granola/hairy armpit crowd. And it was right around the time her migraines had come back...
Having played football as a kid, I knew that dark paint across your cheekbones works better than wearing sunglasses. This works by absorbing light that might otherwise be reflected back into the eye. My hypothesis was that her migraines had subsided when she was wearing eye make-up, including eye-liner and mascara. Her childhood migraines had subsided when she became a teen-ager because that was when she started wearing make-up.
We both had a good chuckle over my hypothesis, and she promised to go back to wearing eye make-up. She hasn't had a migraine in months. No herbs, no zang-fu, no pathomechanisms - just good old fashioned common sense and I got a good result and a happy patient.
I think sometimes TCM pracs become so enamored of our "exotic" medicine that we forget to look for the obvious.
Those are both utterly brilliant stories, Bob's and the one by Shawn Kirby [btw there seems to be a similar story about Dr john f Shen; in that case the patient had been getting headaches because of makeup, specifically a brand of water-proof mascara]. And it's nice to have another post by Bob. I've rarely ever learned as much about Tcm as i did when I stumbled across his forum contributions at tcmstudent.com 
Shawn,
These are great examples on the importance of the questioning aspect of the intake process. Thank you both for sharing your insight and experience. 
Thanks Bob - as always, a very interesting post. 
What great stories -a prerequisite of any inquiry must surely begin with the obvious. A patient would tell me every time she had sugar in her tea she got a sharp stabbing pain in her right eye! Well, after hours of inquisition the final decree was to 'Have your tried taking the spoon out of the cup before drinking?' ...
An old joke, I know but relevant none the less. BUT whether the problem is hereditary or not there is clearly an energetic imbalance which, for whatever reason has been passed down from generation to generation. The physical manifestation simply reflects in this case an energetic imbalance further back than we would normally be concerned with. Let's not opt out of finding a solution for the same reason so often offered by our Western Medical brethren -'it's genetic, you can go home now...'
Symptoms always indicate an imbalance as we know -sometimes however we just need to dig a little deeper with increasing sensitivity to finer frequencies, even if it is genetic, and help our patient release the charge and help break the cycle.
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