Episode Transcript
[00:00:02] Speaker A: Hi, everyone, and welcome to the Nervous Herbalist, a podcast for chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it.
So, basically, we had an idea to create a podcast a while ago, because in our business as chinese medicine practitioners and as people who run a pharmacy, we would get calls from practitioners from time to time, wanting to talk to us about their formulas, have a lot of questions about specifics about the formula, dosage, ingredients, all kind of stuff. And what we realized after fielding a lot of those questions was that a lot of people out there wanted to use herbs. They knew herbs were going to be helpful, but they were nervous about it, and they wanted to.
They wanted someone to help walk them through the process of writing a formula and using herbs. And what was really amazing about that experience was that the formulas that people were suggesting, like the work they had already done before they called us, was good. Right? I mean, like, there wasn't a single time where I was like, oh, that formula is way out of left field.
In most cases, they were on to probably the same thing I would have started with. And it was really just a question of, like, massaging their dosage or maybe add this ingredient as a way to boost or something.
So, anyway, we thought, well, there's a lot of people out there who maybe just need someone to help them along the path of writing more herbal formulas, and that we could potentially provide that information in a kind of asynchronous through the form of a podcast.
[00:01:47] Speaker B: Yeah.
[00:01:48] Speaker A: So, anyway, so we decided this was the way to do that, and we were launching a notion that we're calling the nervous herbalist because it has a little bit of nice alliteration, and it really channels that original idea of these folks actually, really already know what they're doing. They just need a little bit of direction and a little bit of support.
[00:02:08] Speaker B: Right.
[00:02:09] Speaker A: So, anyway, my name is Travis Kernan.
[00:02:12] Speaker B: Yep. And I'm Travis Cunningham.
[00:02:13] Speaker A: And together we run root and branch chinese medicine in Portland, Oregon. And we just wanted to talk to you a little bit today about process and to begin to understand how do we sort through so much of the seemingly overwhelming data that can come at you from a patient interaction and begin to sort of flesh out what an approach can look like.
[00:02:36] Speaker B: Yeah. And we, Travis and I, from the very point we met in school, we noticed some cool things about our friendship that developed that we're different people, that we think different ways, but we often come to similar conclusions at the end of the process that's similar.
Our clinical practice reflects that. So the style of formulas, the style of diagnosis that each of us does is different, but there are points of commonality as well. And so one of the things that we want to do in this series is give you guys a variety of perspectives that can work on an individual case. Like what would Travis K. Do versus Travis C. In this case? How would that look?
And ultimately, we're not going to be in the room with you when you go into the clinic, you know, but you can see kind of how practitioner preference and how we come to the conclusions that we come to.
The other thing that I wanted to say before we get started is that we're only five years into practice, and so part of what we want to put forward is that you don't need, like, decades of experience to use herbs.
[00:04:03] Speaker A: And to use them well and to.
[00:04:04] Speaker B: Use them well to use them effectively.
We started using herbs right out of school as soon as we opened up our clinic day one. Day one.
And about, you know, 80% to 90% of our patients use herbs.
[00:04:19] Speaker A: Pretty much, yeah, I would say we're easily over 90%.
[00:04:23] Speaker B: Over 90%, yeah, at this point. So we use herbs all the time, every day. And we should say, too, that we have an internal medicine leaning clinic. We do treat some orthopedic problems, but we know that, you know, some people out there, they really have orthopedic clinics, but maybe want to incorporate some herbs in their clinic and see if they can get better results. Or maybe you specialize in a certain type of treatment, like you do musculoskeletal pain, but you also see a little bit of acid reflux or you see some IB's or you see some women's health, and you have, like, you want to be able to tie in herbal formulas when appropriate.
I think with a little bit of understanding, a little bit of idea of how the process of prescription works and how to navigate using herbs works. You can do that really effectively without it taking very much time, and you can really increase your clinical results.
[00:05:30] Speaker A: Yeah, I think a lot of people who run, like, orthopedic clinics, high volume clinics, you know, they're seeing three, four, some people, five patients in an hour. They have a hard time imagining, like, how could I possibly really use herbs, you know, and maybe they are using herbs, but they're, you know, just some patents and a little pill version here, a little plaster version there. And the idea of using herbs, you know, seems daunting because of the time constraints and stuff. And I mean, I will say, if you haven't used herbs much since school and you're running a high volume clinic, what we're talking about in much of this podcast is gonna feel like it'd be a bit square peg, round hole, right? Because we're doing a lot of thinking, a lot of processing. But I don't think that they're mutually exclusive. Right. I mean, you might have to get crafty about what stuff do you have preloaded? What kind of templates are you already working with? Do some analysis about the most common types of musculoskeletal cases you've seen in the last year. And if you were to have had time to write a formula from them, you will probably find that there is some thematic consistency there. And so now you've got Chu Yutang family formulas at the front of your mind. You've got, you know, these other blood moving formulas at the front of your mind. So I, you know, if you're listening to the. To the piece and you're like, well, I like herbs, but, like, there's no way that I'd ever have time to do this level of analysis.
Yes and no. Right? In classic chinese medicine, you know, reply, it may not look exactly like this, but to think that, like, herbs are off the table because you see four patients an hour, I think, is to sell yourself short and to miss what's really possible.
[00:07:07] Speaker B: I think a lot of our medicine is adaptable, even, you know, we do. Our focus is internal medicine in our clinic, so we spend a little more time with patients. And I think a lot of our practitioners do, and we use herbs, and we like complex cases, you know, that's kind of our interest, both as practitioners, I think.
So we tend to go that way anyway. But if you are running a higher volume clinic and you want to make the stuff apply and do it faster, I think it just takes a little practice, like thinking through what the common approaches are and doing a little bit of.
One of the things that I like to say to myself to remind myself this is, I don't want to be thinking very much in the clinic. I want the thinking to happen in the back end. Like, I want to think about the cases. I want to have thought about the patterns, the cases, the formulas, either before or after, you know, and as much as I can, I don't want to have to think so much when I'm in the clinic. A couple of this thing here, this thing here, and then I can make my prescription. That's how I want it to go most of the time, there's always cases that are confounding and you have to think about it a little bit more. But for the majority of, I'd say, like, common presentations of things that we see here now, I don't have to think very much about it. I can just person comes in and, you know, how many formulas are there for a UTI? How many formulas are there for a common cold and flu? Most of those presentations are things that, like, you, I think you would agree, right, that you and I have down for sure without having to think about it really too much.
[00:08:59] Speaker A: Bajang san bajing uti.
[00:09:01] Speaker B: Yeah, right?
[00:09:01] Speaker A: Do they have concurrent constipation and dry stool? If yes, keep the dahuang. If no, take it out. There's some, definitely some rote kind of stuff that's connected to it. And, you know, some people out there might be like, yeah, but that's not chinese medicine. That's not customized individual. And I'm like, yeah, but it is though, right? I mean, it's not like every single pattern has, like, a super unique. This is the only key formula that could possibly unlock this pattern. Like, that's just not the case. Right. And so once you've seen some stuff, once you've thought about it ahead of time, I like what you said about this. It's funny because I think people here, like, not don't do the thinking in the clinic. And they're like, what? But there's a lot to be said about that where, especially if you're just doing an herbal consultation, the patient is sitting in front of you. You've just done the ten questions. You've done tongue, pulse, abdominal exam. Maybe you've listened to some lungs or looked in an ear or whatever, and now they're like, okay, so formula. And it's easy to be intimidated by that, to be like, oh, God, I don't know which formula. Whatever. And a lot of the stuff we're going to talk about today, and in this kind of little small series of initial episodes, is to try and clarify process so that you're not sitting in front of the patient, spinning out, being, like, anxious about what's likely to occur next.
So to that end, to highlight something that Travis said as well, we have different approaches and styles now. I mean, we both were trained at OcOM in Portland with the same teachers and the same experience initially. But then once we got out into practice, we sort of found places that we've settled into. So, for example, I use tongue diagnosis a lot. I listen to most people's lungs, even people who don't have respiratory problems.
And then you, Travis, you're doing a lot more with pulse.
Abdominal exam. Yeah, exactly. So there's. There's variation. You know, some people, we have a lot of chinese medicine students who will come and see us, you know, for treatment, and, like, in my case, they'll be like, okay, so do you want to take my pulse? And I'm like, oh, I mean, I'll take the initial one, but I don't really need it afterwards. And they're just, like, flabbergasted by that notion. I don't really use the pulse, like, at all, and I just tell them, I'm like, you know, I never really got much out of it when I was doing it in school, and I didn't. There was so much that you could focus your attention on the. That I chose to focus it on something else. And I don't feel like I'm dramatically missing something because I don't have the pulse. You know what I mean? In the same way that, like, maybe some people just don't really look at tongues or they never touch an abdomen. Like, you don't have to do all the things all the time in order to be, like, a functional and helpful practitioner.
[00:11:51] Speaker B: Right.
[00:11:51] Speaker A: You know what I mean? You got to find what works for you and then stick with it. Like, one of the reasons that I'm listening to so many chests right now, like, I literally. The stethoscope around my neck, like, MD style.
[00:12:01] Speaker B: Yeah.
[00:12:02] Speaker A: Is to, a, to remind myself to listen to people's lungs, and b, because I'm not certain how useful that's going to be to me yet, but until I listen to enough lungs, I won't know.
[00:12:16] Speaker B: Yes.
[00:12:16] Speaker A: So I'm just, like, trying it out.
[00:12:18] Speaker B: Right.
[00:12:19] Speaker A: You know? So do I have a throughput of, like, oh, lungs sound like this? Add shingrin? Like, no, not even close. But as part of my clinical process, I'm just trying on some hats.
[00:12:28] Speaker B: Right.
[00:12:29] Speaker A: And that's one of the things that we want to encourage people to do specifically in the realm of herbs. But I mean, clinically in general, like, you're nervous about it. That's totally reasonable and understandable, but that shouldn't stop you from trying 100%. And that's something I think we. We tell people all the time when they call here, when we're talking to people, like, do your due diligence, think it through, follow best advice, and then just do it.
[00:12:55] Speaker B: Do it.
[00:12:56] Speaker A: Write the formula, because you're not going to know until you do it. No one's going to be able to hand you magic bullet.
[00:13:02] Speaker B: Yep.
[00:13:02] Speaker A: Yeah. So, to guide the walkthrough of process, we're going to use a patient case.
It's an intentionally kind of complicated case that presents, in a way that we see fairly often, where someone walks in, ostensibly with a pretty straightforward complaint. In this case, neck pain. But in reality, as you get talking to the patient, they become. What, what does your guy call them?
[00:13:28] Speaker B: Oh, yeah. And. And.
[00:13:30] Speaker A: And patients. Right. So, like, my neck hurts and I don't sleep well, and I have digestion problem, and I have a really seemingly idiopathic skin condition, and I have horrible nightmares and my menstruation is all over the place and whatever. Right. It's just, there's a whole bunch of things.
And when we were talking to people about making this podcast and we were trying to get some feedback about things we should look at and where to start, one of our friends and colleagues was like, it'd be helpful to know with a really complex case how to start, because here's all these details, like, which of these is the most important piece, right. So, speaking for myself, when I approached that, I think about it in my mind as like a bar graph where each thing in the and goes up at a certain level of discomfort, right? So, like, at the top is just like the most intolerable quality for the patient, and at the bottom is like, I don't notice it at all. Kind of like that numerical scale that we all know is kind of garbage, but everyone still has to use. Right, right. But it's just a mental exercise for me. And so I'm writing my chart, and they're telling me all these symptoms of, and I'm kind of placing them on this bar graph in my mind. And then I ask the questions, some follow up questions to the patient, specific ones. So you've mentioned this neck pain. You've rated it like a seven out of ten, but of all the things we've just discussed, is the neck pain, is that the most bothersome? And a lot of times they'll be like, I mean, yeah, it's a big pain in my ass, but also, it'd be really great if I didn't have to run to the bathroom to pee every 20 minutes. That's actually the thing that's been impacting my life.
[00:15:06] Speaker B: Right.
[00:15:07] Speaker A: And of course, that's not what they came in for. That wasn't the ICD that you wrote down. But in the course of talking to them and listening to their description, all of a sudden urinary frequency is actually much higher, and so that's the first thing that I'm gonna look at. Right. And, of course, like, we're fortunate. Cause chinese medicine, like, okay, their urinary frequency is gonna be connected to the Yang deficiency problem, which is part of their energy problem, which is part of the reason that they don't sleep well, so they don't recover, so their neck hurts. Like, we know that there's gonna be this interwoven quality.
[00:15:38] Speaker B: Yeah.
[00:15:39] Speaker A: But, I mean, it's pretty hard to write a single herb formula that's gonna address all that at once. So you pick the thing for me, I pick the thing that's the loudest from the patient's point of view, and then I work back from there.
[00:15:53] Speaker B: And there's actually a distinction in SAHM acupuncture diagnosis where they talk about some.
[00:15:59] Speaker A: Is the Korean.
[00:16:00] Speaker B: Korean, yeah. Where they talk about what's the loudest thing in the room. So just. You even use that terminology, like, what's loud?
[00:16:07] Speaker A: You know, that's how it feels when I do the ten questions with you, you know, especially if they're. You know, it's chronic. And people dealing with chronic pain. Of course. Like, it's really debilitating.
[00:16:17] Speaker B: Yeah.
[00:16:17] Speaker A: And when they describe it, it feels loud.
[00:16:20] Speaker B: Yeah.
[00:16:20] Speaker A: Like their words get, like, irritated and agitated when they. When they get to the thing that's really bothering them.
[00:16:26] Speaker B: Yeah.
[00:16:26] Speaker A: You know, is that, like. Is that your process, too, for, like, picking what thing to go with?
[00:16:31] Speaker B: I think for me, I try to. This has shifted over time, but the first thing I try to do when people come in now is I try to understand the experience of the problem that they're having really clearly, even if it doesn't relate to pattern differentiation at all. So if somebody comes in with neck pain, I try to, like, I want to understand what it feels like to have the neck pain that they have. Right. And as close as I can get to that, I want to understand that, because then I can sort of. Then it's like the. The data in the computer starts to churn, and then I start to get ideas from, like, what that could be like, you know?
[00:17:13] Speaker A: So are you asking them for, like, clarifying questions about the. So, like, okay, I have neck pain. My neck hurts. Okay. Where does it hurt? Oh, it hurts on the left side.
[00:17:23] Speaker B: Yeah.
[00:17:24] Speaker A: When I turn right.
[00:17:26] Speaker B: Yeah. And it's stuff like we would get taught, like, when did it start? When did you know? When is it worse? Does anything make it better?
When does it most bother you? Is a question I ask a lot.
[00:17:37] Speaker A: Like, time of the day.
[00:17:38] Speaker B: Time of the day, or what are the circumstances of it bothering you the most? When do you notice it the most?
And that kind of. I try to understand the experience of it because I want to be able to talk to the person about how the pattern could or how the formula could address the problem. So for me, the understanding of the chief complaint really helps.
When I go to explain and we're going to do a whole episode, we have planned on talking to the patient. Like, what can you say, even quickly, to inform the patient of what changes are likely with a formula? What changes? What could happen if something goes awry and they start to experience some negative symptoms or something after they take it. Right. But for me, the talk about how to connect the prescription to what's going on and what I want them to look for in terms of changes matters, it's important for me to understand what their experiences are of the problem. So once I have that, once I understand that, then the most important thing to focus on for me symptomatically around the chief complaint has a lot more to do with the different things that I think it would likely be connected to. Right. So if it's neck pain, do they also have headaches? And so then I'm like. And then I start to kind of think about, like, all right, what. What could. What are the different kinds of things that could be connected to neck pain herbally?
It could be that the person's cold all the time. Right. So are we like, is it maybe a gguan sort of Guager gaugen pattern, or is it a counterflow pattern? Is there just some kind of movement upward that we need to address with a whole variety of formulas? Could be a chaihu formula, could be like a wuling son, you know, like, there's a lot of different formulas that can address that kind of counterflow situation. So in my mind, then, the next kind of most interesting information for me corresponds with what's likely to be important for the chief complaint.
[00:19:57] Speaker A: Right.
[00:19:57] Speaker B: I think that's where my mind goes next.
[00:19:59] Speaker A: So you're taking the chief complaint and then looking for direct corollaries to the chief complaint in order to flesh out the pattern. Yeah, yeah. And I. I think I differ here in that while, of course, whatever brought the patient in is the thing that we want to primarily treat, because otherwise, you won't have patient buy in and they won't come back. Right. So they came in for back pain, and you treated like they're like loose stool. Right. Is not. Is not going to get the patient to come back. But a lot of times I find in my questioning that what the patient actually wrote down as their chief complaint may or may not actually be the thing that's bugging them the most. True. You know what I mean? And so if that's the case, then I, then I guide their pivot, right. And find another thing. A lot of times, too, like in this case, we're going to present, the patient did come in with neck pain as the primary complaint, but a lot of times people will come in and like, you know, they couldn't even prioritize which of the things that is bugging them is the chief complaint. Like, we force them into that model, by the way, charting is done and stuff, right? But, like, they sleep terribly, they have constant loose stool, and they are chronically fatigued. Which of those things is their chief complaint? Like, a lot of times patients need help clarifying it on their own end because, like, well, could you just fix all of it? Right? It's like, well, I mean, yeah, maybe, probably even. But, like, we're going to have to be systematic about it. So if you're looking at a case where the chief complaint is clear, the patient is clear about what is the thing that's bugging them the most. It's the same thing they listed as the chief complaint. Then starting to think about connected problems, ancillary conditions that'll help clarify the various things that can cause. Like, in this case, neck pain is probably the best move. If they come in and they've got this whole collection of problems and they're having a hard time sorting them, you can catalog those problems with them in the ten questions. And then this is the whack a mole. This is the whack a mole position that you're in. You pick the thing on the bar graph that is the highest, and then you make that call and communicate that to the patient. So obviously you want to give the patient what they're asking for first and foremost. But if it's unclear exactly what they're asking for or they don't know, this is how you can step in to clarify that for them. And my advice is pick the loudest thing in the room and then just go from there.
So let me lay out the details of this case.
And then I kind of want to set it up so that maybe you can ask me some questions, like as if I were the patient. So for the listeners to know, I've been seeing this patient for almost four years now, which is kind of crazy. Almost the whole time we've been here through Covid, all kind of stuff, and we've worked on a whole host of problems. But I've gone back into the chart, and I pulled out the original chart from the very first time she came in, and we're going to kind of work from there because that'll sort of set the stage for the complexity of what is to come. So this patient, 50 year old female, came into the clinic presenting with neck pain. Right. So she had this really gnarly neck pain, and in addition to that neck pain, kind of like what you were saying, she, on the day she came in, she's been having a chronic headache. So she's got this really gnarly neck pain that affects her ability to rotate in regular motion. So she can only get, like, about 15 degrees from the center line in either direction. Right. So it's pretty limited motion. She can bend forward and back, flex and extend, no problem. But it's the rotation where the pain was serious, and so it's massively affected her ability to work. She works at a desk, in an office. This is pre Covid, so she's not working from home. And when she would turn to talk to me about it, she would, like, shift her whole spine. Like, instead of turning her neck, she would turn her shoulders so that she could look at me and address the problem.
But of course. So that's what she's coming in for. That's what we asked a lot of questions about. But while she was sitting in front of me, she had this brutal headache. Right. So she's got frontal location headache. It's throbbing in the front, but it also, like, usually begins at the occiput and then moves over the top of her head and then lands in the front, throbbing in the front, sometimes still at the occiput, sometimes not. Right. And she will take ibuprofen to help with the pain, which it helps with almost immediately. But she reports having an allergic reaction to ibuprofen, which causes shortness of breath, chest tightness, itching, skin irritation, all kind of stuff. And usually then she has to use a rescue inhaler in order to be able to continue to comfortably breathe after taking the ibuprofen. Right. So she's really resistant to taking it, understandably, because it makes her feel so uncomfortable. So a lot of times she just tolerates these headaches. Right. And the neck pain and any other body pain. So I flesh out all the details of this stuff.
What makes it better, what makes it worse. Right.
And it seems kind of random from her experience, if it's going to be bad, though, it's usually bad at the end of the day, as opposed to in the beginning of the day.
And the headaches can come even when there isn't neck pain. Headaches have been a constant portion of her life for a whole life. Right? But right now, it seems to be directly connected to this ongoing neck pain. No injury, shouldn't do anything, didn't spin, it, didn't get hit, and she's had on and off neck pain over the years. She thinks it's somewhat postural connected to work, for sure, but she's not really sure why it happened. So I pull all that information together, and then I go into the ten questions. Right. Just classic ten questions to gather the information that's there. So before I do that, let's pretend that I'm the patient in this case. So, from your point of view, I've given you the physical symptoms. What else do you want to know at that stage?
[00:26:00] Speaker B: So, patient having a difficult time turning side to side. The first thing that I think of is the description of Chaihuji Longo Mulitang, because there's literally a line that says difficulty turning side to side. So that's the first thing that pops up on my radar. So the first thing I want to check in terms of a pattern is I want to understand if there's a xiaoyang pattern. So she's got a headache, there's some dynamic of yang getting stuck in the head. So I want to understand why that's happening. So the first thing I would check for, partially because I know this is super common with patients in general, but I want to see if the obstruction is at the xiaoyang level. Right. And I tend to use six confirmation diagnosis for my herbal practice a lot. That's the main system that I use. So I would think I would try. I would test that one out first, I think. So I would ask about strange taste in the mouth.
No, strange taste in the mouth. Any feeling of stuckness or dryness in the throat?
[00:27:12] Speaker A: Yes. Tendency toward thirst. Drinks a lot of water, but still thirsty and easy sore throat with changes in the weather and dry air.
[00:27:22] Speaker B: Yeah.
So then I would think, okay, that's now looking a little more likely. And then, does she ever get dizzy would be my next question.
[00:27:31] Speaker A: Absolutely.
[00:27:32] Speaker B: Right. So we've got two of the three t gong lines for xiaoyang disease already.
So then I'm thinking, like, okay, that's pretty. I'm leaning in that direction.
But I also wanna understand, like, okay, person could feel dizzy. There could be these symptoms because of a fluid problem. Right. Some kind of damp problem. So that would be another thing that I would wanna check out, check up on. So I would wanna ask about. Well, you already said thirst, right?
[00:28:03] Speaker A: Yep.
And that would be part of my ten question process anyway, even if I forgot to think about it for the physical bit. And so that the listeners know the patient is slightly shorter than average height and carries a little extra body weight with significant lower leg edema, sometimes pitting, but not always, and has a tendency toward phlegm accumulation and a clear dampness, just a constitutional level of dampness that's very evident just by talking to the patient and feeling the quality of her skin and things like that, seeing the edema.
So to that point, to the dampness question, then that would become increasingly apparent, of course, in the ten question bits. So I always ask my ten questions in the same order over and over again just to kind of, like, build some regularity around that. Right. And sometimes my ten questions is actually only nine questions because how I get into the emotional bit can kind of be scattered into the other pieces. Yeah.
So I always start with appetite. So the patient's appetite is hungry before meals, eats three meals a day, is regular, but has a long history of digestive weakness that she reports to me super sensitive to foods, has a whole list of foods that she doesn't eat that will cause abdominal pain, bloating, loose stool, frequent stool, and a lot of those things are things that we see a lot in the clinic. So wheat, sugar, mushrooms of all kinds, and then just some sort of, like, random things that are sort of sweet flavor and sort of not so, like, you know, dried chips. Okay, that's sweet flavor. But then also, like, almonds are out. Right. You know, from her point of view, it's not exactly clear why almonds are out. Right. And in the course of working with her, over time, we actually discovered a lot of other things that she knew about already but just didn't come up, you know, because list all the things that you feel allergic to is a little overwhelming for someone who has had a long history of them. But serapitate is good. She eats regularly, but she's very cautious about what she eats and generally very focused on it.
[00:30:19] Speaker B: Yeah.
[00:30:20] Speaker A: But then we'll also sometimes then just completely punt on a kind of restrictive diet and just sort of, like, eat whatever.
[00:30:27] Speaker B: Yeah. Kind of oscillate that.
[00:30:28] Speaker A: Yeah, just like that. Jell o and cake and whatever.
[00:30:32] Speaker B: Right.
[00:30:34] Speaker A: So when she eats regularly and has a regular meal her the feeling of digestion. My second ten question is pretty manageable, but she always feels a little bloated and gassy. So it's not like gurgling, nausea, stuff like that, but pretty much everything makes her feel a little bit bloated and gassy.
She has one to two bowel movements a day, so nothing out of the ordinary. They are mostly formed, but they can easily go to hard constipation. So hard and infrequent, or they can easily go to loose and more frequently. So there's an easy vacillation in either direction. And it has a lot to do with what she eats and then thirst. We mentioned she's easily thirsty, though. She drinks a lot of water in the day, quick to have dry mouth, and with urination, she doesn't have any reported issue. So no urgency, no frequency, no burning, no pale color, no blood, no cloudiness.
She sometimes, like, it's mostly clear to pale yellow, you know, so from that point of view, no particular issues.
Temperature, she tends to run cold historically, but of late has felt warmer.
[00:31:47] Speaker B: Yeah.
[00:31:48] Speaker A: With things kind of surging upward with. With flushes. She is 50, so she's perimenopausal. Right. Her. Her menstruation is not regular anymore, but historically was a five day bleed with a little bit clots, blood, brighter in color, but no long history of, like, complicated menstruation. But now because she's perimenopausal, that that picture is changing. Right.
And perhaps part of that when she walked in and also maybe just other changes. She was having these hot flashes, right. She didn't describe them as hot flashes, but as mild flushes.
[00:32:23] Speaker B: Sure.
[00:32:23] Speaker A: But it seemed to be leaning in that direction.
[00:32:25] Speaker B: Temperature alteration.
[00:32:26] Speaker A: Yeah.
[00:32:27] Speaker B: Yeah.
[00:32:27] Speaker A: Cold hands and feet. Yep, for sure. Cold hands and feet.
Would prefer a breeze and some cooler weather. Does not like the summer. Hot summer, not a fan. Regular night sweats two to three times a week, completely having to, like, change their clothes. Like, soaked through. Right. But otherwise, throughout the day, no random sweating. So even with a mild flash, like a hot flash, no sweating to go along with it. No irregular sweats, no cold sweats, nothing like that. So night sweatshi, but pretty severe.
She feels rundown and fatigued all the time. Has for months and months. And when it comes to her sleep process, she falls asleep pretty easily, but wakes easily as well and has pretty dream disturbed sleep. Lot of intensity in the dream, sometimes violence in the dreams. It feels very frenetic.
[00:33:17] Speaker B: Yeah.
[00:33:18] Speaker A: And then in her case, the emotional state is prone to worry a little bit of a kind of high strung, anxious vibe, but she has a lot going on. She has a disabled husband. She is the primary breadwinner. She's very successful in her work, but there's a lot of expectations put on her by colleagues and supervisors and things like that, in addition to generally feeling tired, rundown with body pain and weak digestion.
[00:33:45] Speaker B: Yeah.
[00:33:46] Speaker A: So anyway, that's all the information I gathered.
Sometimes, you know, again, when you're looking at a complex case, sometimes if you read a case study or you hear it like we're describing and hear someone listening, is like, oh, my God, it's so much information. Like, how am I supposed to parse it totally? But when I do my ten questions, one of the reasons I ask them in the same order every time is because I'm running a little checklist in my mind, right? Like, I've asked about the physical things, I can see the dampness that's in front of me. So now when I'm asking questions about appetite, I'm thinking I need to confirm the level of dampness in the system. Here is what I'm looking for. Right. So when I'm asking questions about appetite and bowel movement, I have a little bit expectation of what she's likely to say back. Right. And of course, we've seen now, of course, after many years, people that tend to have chronic dampness and weak mental jows also tend to be allergic to foods easily. They have really vacillating bowel movements, usually tending toward loose, in my experience, versus constipated. Versus hard and constipated, but not always.
[00:34:48] Speaker B: Right? Not always.
[00:34:48] Speaker A: They go back and forth. And so, like, as she's telling me this in my mind, in my imaginary checklist of, like, there's. There's a significant dampness level I'm just kind of checking. Yes.
[00:34:57] Speaker B: Yeah.
[00:34:58] Speaker A: The exact specifics are less important to me when I'm doing the initial framing than confirming some suspicions. Right, right. And then if she said something like, oh, yes, I only have a bowel movement once every four days, and it's hard and dry. And it's only ever been that way, hard and dry. Now I'm thinking, okay, I see the dampness in her body, but there must be something else going on because that is not typical of dampness in the digestion. And that is the kind of way that I'm going to sort what seems on initially to be a lot of information. Right. I'm running it against a checklist in my mind, right. And where does the checklist come from. That's a natural question. Where does the checklist come from? It comes from our training. I mean, it literally just comes from. What does dampness look like in digestion? What does dampness look like in bodies? What does dampness look like in pain conditions? Right. And if that's something that doesn't immediately pull to the front of your mind, like, no problem, right? School might have been a while ago. It's just stuff to go and read about. Right? I mean, you can read case study manuals. You can read commentaries on books. You can do continuing ed. Right.
So don't be intimidated if you're like, I don't have. I don't have that checklist immediately available. Yeah, that's fine. Right? That's. That is the stuff, like you were talking about that you think about before the treatment and after the treatment and after.
[00:36:18] Speaker B: Yeah.
[00:36:19] Speaker A: Right.
[00:36:19] Speaker B: And eventually that builds, you know, like, you. You program the computer, and then you go in and boom, boom, boom. Makes all kinds of connections there.
Yeah. I think with. With my process, I have a suspicion, like, the way that I now work is I'll have a suspicion about what something could be, and then I will basically try to prove myself wrong. So I'll, like, I'll look for, like, all right, dampness seems to be an issue. So let's confirm. Let's talk about fluids. Like, I'm going to ask my fluid questions. So there's thirst, there's urination.
And an important part of urination, I think, that I didn't ask in the beginning that I now emphasize is hesitation. Is there hesitation? Does it take you a minute to start?
And most people will not tell you that that's the case before you ask that specifically.
[00:37:21] Speaker A: Absolutely.
[00:37:22] Speaker B: And any kind of weird stuff with urination, to me, goes up with, like, there's some problem with the body processing fluids. The bladder chi is having a hard time transforming.
[00:37:32] Speaker A: I phrase that follow up as any difficulty starting or stopping.
[00:37:36] Speaker B: Yeah, perfect.
[00:37:37] Speaker A: Because it could be either.
[00:37:39] Speaker B: Yep.
[00:37:39] Speaker A: Yeah. And obviously, this goes perhaps without saying, but I guess we'll say it anyway. Whenever you're asking people questions about, especially bodily functions, you have to design a sufficiently open ended question that is also targeted.
[00:37:52] Speaker B: Yeah.
[00:37:53] Speaker A: Right. So you can't just be like, how's your digestion?
[00:37:56] Speaker B: Right?
[00:37:56] Speaker A: Because pretty much everyone will say, fine.
[00:37:58] Speaker B: Right. It's normal.
[00:38:00] Speaker A: It's normal, it's fine. You know how. Any issues with bowel movement? Nope.
Okay, how many bowel movements are you having a day? Oh, I only have one every four days.
[00:38:10] Speaker B: Right.
[00:38:11] Speaker A: Okay, well, that's a problem. Right. But if you just ask, how's digestion? How's bowel movement? Any issues with. You're going for an open ended question because you don't want to box someone into a specific response and create a confirmation bias. But your question is so open that you won't really get any useful information. So you can start with an open ended question and see if they offer a response, but then you need to follow up with some specific follow up questions that give the patient some language to describe what it is you're looking for. Right. Often I will actually open up with any particular issues. So what I usually say is, after you have a meal, how does your digestion feel? That's usually what I say. And then a lot of times that's open ended. So a lot of people will just say, fine. And so then I'm like, any issues with gas or bloating? Yes, I feel bloated all the time. Okay. How about any acid reflux or heartburn? Yeah, sometimes when I lay down. Right. So, you know, we went from any. After you eat, how does your digestion feel? Fine. Two, I'm always bloated and gassy, and I have relatively frequent heartburn.
[00:39:19] Speaker B: Right. Classic.
[00:39:20] Speaker A: Yeah. So, like, that, if you stop at fine, you wouldn't get that information. Right. Now, this is the art of the interview. Right. Because you also don't want to give the patient, like, a rapid fire bullet list of every possible thing that could remotely be part of their presentation. Right. So you'll have to, like, kind of mix and mix and match to get some response. But don't ever let the patient off the hook with a it's fine response.
[00:39:49] Speaker B: Right.
[00:39:49] Speaker A: Gotta have one, two, maybe three follow up questions to clarify. And those follow up questions should be relevant to your thinking. Right. How is heartburn helpful to me? Well, it tells me that there's some kind of middle jow resurgence. Is it running piglet? Is it Yang rising? Is it stomach heat? Is it stomach Yin Shu? Like, there's a lot of questions, but the fact that there is heartburn is relevant now, and I've got to work from that.
[00:40:17] Speaker B: Yep.
[00:40:17] Speaker A: So, anyway, based on those symptoms from this patient and you're thinking in this xiaoyang space, what else would you want to know?
[00:40:29] Speaker B: So I would ask a couple questions, like, the ones that I think are the most interesting or relevant. Right. And I almost always ask about bowel movement, no matter what. You know, that's, like, a pretty good keystone question to ask, but I want to get, like, I don't want to, I want to talk to the person long enough.
This is where I've gotten to.
I want to talk to them long enough so that the problem is clearly described, so that they feel heard, so that I feel like I understand what's happening with them and I want to ask a few questions surrounding it, but I want to get them on the table so that I can palpate and do the other things relatively quickly at this stage for me, because I want to get, I want to see, like, what's there as a kind of the, I want to see what the picture is before I ask more specific questions. So I have them get on the table. I either feel the pulse before they get on the table, or sometimes I'll do it after they're on the table.
At this stage, I think it doesn't matter a ton for me.
I'll feel the pulse. If they're on the table, I'll go to the left side. Just happens to be the way that my office is set up where I'll feel the left pulse, then I'll feel the right pulse, then I'll palpate the abdomen because the Fukushin system they have you palpate standing on the patient's right, if that makes sense.
So I set it up that way. And then if I want to look at the tongue, I'll look at it after I do the abdominal palpation.
[00:42:07] Speaker A: So they're lying on the table?
[00:42:08] Speaker B: They're lying on the table.
[00:42:09] Speaker A: Yeah.
[00:42:09] Speaker B: Yeah. But, you know, a good distinction between the way you practice and the way I practice is I don't use the tongue very much. You know, I use the other stuff way more. So I want to see, like, alright, which areas are tender on the abdomen. Right? So for xiaoyang, I'm thinking about, like, under the ribs. Can I hear their guts gurgling? Can I hear water moving around? And if I can, my first question is, did you just have something to drink? Right. Because you want to rule out people can have sloshing if they just had some water out in your office.
[00:42:43] Speaker A: Like, they stick out their tongue and it's really yellow and you're like, did you, if you don't ask that they had something to drink, they could have just like downed a beverage or coffee.
[00:42:52] Speaker B: Coffee or something. Exactly.
[00:42:54] Speaker A: Yeah, you gotta ask.
[00:42:55] Speaker B: So you gotta, you gotta think about those things.
But you wanna listen to sound like I listen to sounds in the abdomen. If there's gurgling, I take that into account. That would lead me more to a flow fluid processing problem, you know, or you can. You can tap on the abdomen to try to elicit fluid sounds.
[00:43:17] Speaker A: That's sloshing sound, right?
[00:43:19] Speaker B: Sloshing, yeah.
So I would want to do that stuff because that would also help me to clarify, like, all right, which direction is. Is attending the show up in this person? And the pulse, I'd say, is the main diagnostic system that I use to at this point. So is the pulse real in this patient? Is the pulse wiry? You know, period? Is it wiry, or is it really soft? Like, is it stronger, or is it really soft? Is it thinner? Like, can I feel the outline of the vessel? Or is the whole thing kind of blurred? And, like, I'm. It's, like, muffled or it's behind a screen or something like that, and I can't really feel. Feel the vessel very clearly. Those are the kinds of things that are going to lead me to. All right, maybe there's more constraint. Maybe there's a movement issue, like, in the sanjiao. So that would be more like a xiaoyang type of thing. Or is it more of a fluid problem? Is the pulse just, like, muffled and soggy and it just feels, like, thick, like it's not able to articulate its.
Its quality correctly? And it could be both. So, like, with this patient, as she's been described so far, I think I would treat both at this point. I would be looking at formulas that would treat xiaoyang and would treat the fluid problem.
I might even lean into a chaihu jia longu mulitang because of the sleep. Like that difficulty with the sleep, the restlessness, the getting up at night and the night sweating, to me, indicates that flushing up of yang in the night, when the yang should be anchored deep down.
And that formula also treats problematic urination, which she didn't report. But if there's a fluid problem, it's reasonable to want to use a formula like wuling san or like a lingui jugan tangin. And I know the patient's sensitive to fungus, right? Or mushrooms.
[00:45:24] Speaker A: Yeah, mushrooms. That is fooling for everybody out there listening. And, of course, in a person with such visible edema and wetness. Right. Fooling would be a natural go to. In fact, it would be like in every formula that you can think of. And we had to pull it, we couldn't use it, and we had to get kind of crafty about what to do. So, interestingly. So I also want to point this out, and when we were in school, there was a lot of emphasis on writing out a differential diagnosis. So, like, spleen chi deficiency with concurrent wood overacting, spleen whatever.
I never write those.
[00:46:03] Speaker B: Oh, no, I don't either.
[00:46:04] Speaker A: I never write those. And there's nothing wrong with writing them. I'm not saying it's a bad model. In fact, I think it's very helpful when you're in school to try and force you into a pattern thing. But it has been my experience that spending too much time trying to craft a differential that makes sense, like, not only, like, has all the words, addresses the whole case, but actually, pathomechanically, actually would be possible, is really hard. And the hard part is not the thing that deters me from doing it, it's that I actually then don't find it very useful. Yes, true, because a lot of the patients that we see are really complicated cases. And so this patient has a fluid metabolism problem living in the San jow. She has middle jow spleen deficiency with damp accumulation, a kidney yang problem, lung weakness, difficulty grasping air. So we know the kidneys involved. Like, how many things you want to list in that differential? I mean, basically, you've just described her case in chinese medicine terms. But that's not going to help you write your formula, right? That's not even going to help you. I mean, it's not going to help me. Maybe it's going to help someone, but it doesn't help me write the formula. It doesn't help me even really understand what's happening, because all I really did was take the symptom set and the observable data from tongue and abdomen and pulse and turn it into chinese medicine jargon. Right, right. So, you know, I don't know that that's very helpful. What I do instead is I pick the things that I think are the loudest in the room, as we've said, not only from, like, initially we were talking about in terms of chief complaint, but now I'm talking about it in terms of pathogenesis. Like, what is the pathogen? That's. That is the loudest that I can see. That's then also connected to the chief complaint, and then I'm going to treat that. So, like, for me, with this particular patient, it was the damp accumulation. And, you know, I don't know in this first visit if I was really able, you know, and again, I've been seeing this patient for a long time now. So my perspective on her problems has evolved in a way that is only possible when you've seen someone many dozens of times over several years. Right. And so, at the time, though, the thing that stood out to me, the most was the very clear dampness and the kind of high strung quality.
[00:48:28] Speaker B: Yes.
[00:48:29] Speaker A: So I was like, okay, how can I address this kind of livery agitation and the dampness together, especially with cold hands and feet and especially with this kind of weird vacillating temperature? So I reached out, of course, went to the Chaihu family groupings. Okay, which Chihuahu formula am I going to use? Use? And I picked. I started with Chiyu shugansan, and that was a couple of reasons. One, so I could get out the wiry livery thing. And also, Chayu shugan san is a pretty dry formula. Right, right. And, you know, the chenpi and stuff in it, like, it'll. It'll dry fluid. That's what I was thinking. Right. And then I was like, oh, we also need to put, like, I don't want just dry her out, though. I want to send those fluids a direction. So I basically took out, took parts of wuling san and jammed them into this Chaiushukan san. So I was like, all right, chai, yushu, Ganzan, plus, you know, like, some guizhou and some zhixia and some, you know. But I couldn't use fu ling. Right, right. So I write this formula thinking, okay, she's gonna chill out a little bit. It's gonna start to drain downward, this stuff that's accumulating upward. And her neck's gonna feel a little bit better. The headache, you know, because she's got this frontal headache, it's living in the front. I'm thinking sinuses, I'm thinking stomach. I'm thinking damp wetness accumulation.
And she's a big fan of sugar. And so I thought, okay, all these things point to dampness. Let's get rid of the dampness, and we'll help. The thing is, is I did not take into account properly the thirst thing.
[00:50:03] Speaker B: Yeah.
[00:50:04] Speaker A: Right. I just sort of scooted on past it because I was so focused on draining the dampness. And the thing is, is that she started urinating way more frequently. The headaches went away. Okay.
She also had some post nasal drip that also stopped, and she had better circulation in her hands and feet. Like, great, great, great. Also, she tells me that her mouth feels like the Sahara desert. She has a sore throat, and after seven days of taking the formula, she described her sinuses as female, feeling crunchy. Right.
And she was, like, starting to have pain and discomfort of an entirely different sort in her crunchy sinuses.
And when, you know, upon reflection and upon sitting here talking with you about it now, four years later, with the more experience that we have. It was like, well, yeah, like, of course that's what happened. Right? Like, Chayu shugan san, unless it was significantly modified, Chayushu Ganson, as it was, was too dry for this type of drainage, drying needs. Right. If that makes sense. Like, so, of course, it is a drying formula, but the type of herbs in it, the Chen P in particular, like, that kind of stuff, it's just too dry for someone with dry throat, dry mouth. Right. You got to move foods in a different way. So, that said, the patient had a huge amount of buy in because I actually corrected a whole cluster of the primary things that she came in for.
She just had these crunchy sinuses.
And so we just pivoted in that moment to make it work. And this really gets to the core question, which is, once you have the diagnosis, now we've got to build the formula, and then you got to deal with the outcomes. And that is the greater specifics of what we want to talk about in upcoming episodes. Right. I mean, we just gave you the summary highlights of where it went, but I think it would be better if people could get into our thinking about it. And I really want them to hear, you know, based on the symptoms as we've described them to them in the next episode. I want them to hear how you would build a formula.
[00:52:17] Speaker B: Right.
[00:52:18] Speaker A: Because in this case, we have Travis Kern's four year old experience building a formula and error of it. But now we have your ability to look at the case study and build it with your current level of experience, and we can use that to compare the difference. Right. What would we be thinking about now ahead of time? How would you build the formula, given the symptoms that are in front of you and the data that you were able to collect.
[00:52:43] Speaker B: Right.
[00:52:44] Speaker A: And then kind of design, use the next episode as a way to start to understand composition.
[00:52:49] Speaker B: Yeah.
[00:52:50] Speaker A: So you've done your analysis. You've thought through your pathomechanism. Maybe you wrote out a differential. But as I said, with complicated cases, sometimes differential, not very helpful.
And now it's time to write the formula.
[00:53:03] Speaker B: Right.
[00:53:04] Speaker A: And that is the thing that we want to do next time, right?
[00:53:07] Speaker B: Yep.
[00:53:08] Speaker A: Okay. Sounds good. Sounds good. Until next time, then, friends.
[00:53:11] Speaker B: Yep. See you next time.
