24. Diagnosis – the purpose and process
Chapter contents
Introduction to the diagnosis chapters182
The purpose of making a diagnosis182
The process of making a diagnosis183
The stages of making a diagnosis184
The stages of taking a case history185
Pulling it all together188
Rapport188
Introduction to the diagnosis chapters
‘To see’, ‘to hear’, ‘to ask’ and ‘to feel/smell’ are the four traditional methods of diagnosis used in Chinese medicine. To use these diagnostic tools, practitioners both employ their senses as well as ask questions. Some styles of diagnosis pay more attention to one or the other of these methods. For example, contemporary Chinese herbalists emphasise asking questions about the complaint and the patient’s general condition. Although they also use hearing, looking and feeling, these are generally considered less important than questioning. In contrast, practitioners of Five Element Constitutional Acupuncture ask fewer questions and are more reliant on seeing, hearing, smelling and feeling. For this reason the five chapters on diagnosis pay special attention to how practitioners can use and develop their senses in order to make an accurate Five Element diagnosis.
In this first chapter on diagnosis two main aspects are described. The first is how to record the case history and make a diagnosis, and the second is the importance of developing rapport and how to achieve it.
The second chapter (Chapter 25) covers the essential methods used when diagnosing the CF. These are the observation of colour, odour, sound and emotion.
The following chapter (Chapter 26) is about body language and observing a patient’s posture, gestures and facial expression. It illustrates how much assessment of a patient is carried out by simple observation.
The next chapter (Chapter 27) on diagnosis covers two important areas. One is reading ‘golden keys’. Golden keys are unusual aspects of a patient’s behaviour or values that may support a CF diagnosis. The other is determining the appropriate level of treatment the patient requires. This may be the body, mind and/or the spirit.
Finally, the fifth chapter of the diagnosis section (Chapter 28) covers much of what comes under the area of ‘to feel’ and the physical examination of the patient. The specific areas covered are pulse diagnosis, the Akabane test, feeling the three jiao and the palpation of the abdomen. These methods of diagnosis can indicate that an Element is significantly out of balance and they can also support the diagnosis of the CF. However, they are less important in actually determining the CF.
The purpose of making a diagnosis
The main goals of making a Five Element Constitutional diagnosis are:
• to diagnose the patient’s CF
• to determine if any other Elements require treatment
• to establish whether the patient has any blocks to treatment
• to ascertain the level of treatment required – body, mind or spirit
Diagnosing the patient’s CF
The main goal of diagnosis is to find the patient’s CF. Once the CF has been confirmed, it will be the basis of much of the treatment. This is because using points associated with the Organs of the CF are likely to have the most significant effect on the patient’s overall health. Having said this, there are situations when this is not the case. For example, acute problems such as infections usually respond better to points chosen to clear the symptoms directly. Also, patients with acute traumatic injuries have better changes from points that move qi in the area of the trauma than from treatment centred on the CF.
Diagnosing the other Elements
Determining the patient’s CF involves an assessment of all of the Elements. Whilst making the diagnosis the practitioner forms an opinion about the balance of each one. The basis for diagnosing an imbalance in any Element is the same as determining the CF. The main difference is the intensity and number of the diagnostic indicators. Knowing that an Element other than the CF Element is weak is crucial.
A person may be a Water CF, for example, but in the aftermath of an unhappy love affair the Fire Element may be devastated for a considerable period of time. Alternatively this person’s Metal Element could be shattered by a recent bereavement.
In many cases treatment on the CF greatly improves the balance of all of the other Elements. Sometimes, however, one Element does not respond and treatment also needs to be directed to that Element. In these situations the practitioner may decide to treat the affected Element as well as influencing it indirectly by treating the CF. This will re-establish harmony within the Five Elements, which will in turn help the person to overcome heartbreak or endure loss with greater internal strength and fortitude.
Diagnosing possible blocks
Next the practitioner needs to establish whether the patient has any blocks to treatment. If blocks are present, they have to be cleared first. They are:
• Aggressive Energy
• Possession
• Husband–Wife imbalance
• Exit–Entry blocks
Diagnosing the level of treatment
During the course of the diagnosis the practitioner assesses whether treatment should be directed more towards the patient’s body, mind or spirit. Determining which level most requires treatment is important as it affects point selection. More is written about this area of diagnosis in Chapter 27.
The process of making a diagnosis
Recording the main complaint, systems and other information
A Five Element Constitutional Acupuncturist always takes a full case history. This involves asking about many areas including:
• the patient’s main complaint
• the health of the ‘systems’, such as the digestion, cardiovascular, urinary and reproductive system
• the general health of the patient’s parents and family
• the patient’s medical history and educational, work and personal history
• the patient’s current living and relationship situation, work, interests, etc.
A Five Element Constitutional Acupuncturist does not use the actual content of this information in order to make a diagnosis of the CF, but it is still important in three ways.
• Firstly, many opportunities for emotion testing will arise whilst collecting this information. Emotion testing will be described in the next chapter. The practitioner can also notice the patient’s colour, voice tone and odour during this time. Rapport is also established.
• Secondly, it helps to set a benchmark for the patient’s current health. Patients are often most concerned about their main complaint when they first come for treatment. Consequently they may not mention other systems that are not functioning well. For example, some patient’s bowels may be too frequent or their sleep patterns less than optimum. Patients may also tell the practitioner about other areas of their lives where they are experiencing difficulties, for example in work situations, friendships or close relationships. When practitioners know about all of these areas they can monitor the patient’s progress. Many aspects of a patient’s health improve when the root is treated. Monitoring this information often tells a practitioner that the patient is getting better even when the main complaint has not yet responded. As well as helping to monitor treatment, patients will also benefit from a wider notion of what constitutes health.
• Thirdly, this information can, in spite of what was said previously, help to confirm the diagnosis. For example, the history of the complaint may reveal that it began shortly after leaving home, the break-up of a relationship or after a frightening experience. The emotional response to these situations may reveal which Element has become imbalanced. This information is never the basis of a diagnosis, but it can confirm and support it. People’s health and welfare depends on them being able to receive nourishment from all of the Elements on a regular basis. External changes to their ability to receive this nourishment may reflect on their health. The patient who developed multiple sclerosis after her child ran away or the patient who became ill after his one constant source of love and affection walked out, can be telling us something significant. Patients’ non-verbal expressions can be as significant as their words.
What a diagnosis does not involve
A Five Element Constitutional Acupuncturist makes a diagnosis based upon the person who has the illness rather than the nature of the illness itself. Therefore the main complaint or symptoms suffered by the patient are important, but are not used to make the diagnosis. The fact that the patient is constipated, paralysed or suffering from migraines is not a basis for the CF diagnosis. The patient’s Western diagnosis, for example, rheumatoid arthritis, manic depression or diabetes, is also never the basis of a diagnosis. Symptoms often reveal that an Organ is dysfunctional but do not indicate whether that Organ is the primary or secondary cause of the problem.
The stages of making a diagnosis
The context of treatment
Throughout this book, when we refer to practitioners making a diagnosis, we assume they are working in a professional context. This means that the practitioner diagnoses, then treats a patient, and that this is carried out in the practitioner’s acupuncture practice.
Most practitioners sometimes find themselves making a diagnosis in other contexts. For example, a friend may call to consult on the telephone or someone at a party might talk about a problem she or he is having. It is useful for practitioners to apply their diagnostic skills in many different situations if they wish to develop them. It is not appropriate, however, to treat in these situations. We recommend that, if a diagnosis is to lead to treatment, the practitioner should carry out a complete diagnosis and have appropriate conditions under which to administer the treatment.
The two levels of activity during a diagnosis
While taking a case history, practitioners are frequently operating on two levels at once. Whilst doing the ‘business’ of taking the case history, they may also be making significant interventions and observations. Although there are various stages to the process of making a diagnosis, many of them can be done at almost any time. For example, looking at colour, smelling an odour, observing the person’s emotional state, recording childhood diseases or taking pulses can be done in any sequence.
Often more than one activity is carried out at any one time. For example, while practitioners are discussing and recording the patient’s main complaint, they may also be attempting to discern the facial colour, odour and sound in the voice. Alternatively, when a patient is describing a pain, as well as recording its nature, location and intensity, it may also be a perfect moment for the practitioner to give sympathy and assess the emotion of the Earth Element. There are more examples of ways that practitioners operate on two levels in the next chapter.
The stages of taking a case history
The following are the main stages of taking a case history. This is only one sequence and case histories can be taken in many different ways. Newly qualified practitioners or those just starting to use this system of acupuncture are recommended to more or less follow the sequence laid out below. At the same time, as long as the practitioner gains the essential outcomes of a Five Element Constitutional diagnosis (see above), then they can work in any order.
The stages of the case history are:
1 establishing rapport
2 taking the main complaint
3 questioning the systems
4 finding out about personal health history, family health history, relationships and present situation
5 ‘to feel’
6 ‘to see’
Establishing rapport
Establishing rapport is the first priority when making a diagnosis. Without rapport practitioners are operating without the patient’s trust. As a result patients are less likely to co-operate and disclose themselves freely. Instead they will wonder if they have chosen the right practitioner and will hold themselves back until they are sure. Although rapport-making is an activity that can be carried out on its own, it is also something that is done at the same time as taking the case history.
At various times when taking the case history, especially early on, the practitioner will focus almost exclusively on the development of rapport. At other moments it will be a background consideration. Although in one sense rapport comes first, it also continues throughout the case history. Rapport-making is discussed in more detail later in this chapter.
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