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Chinese Medicine Times

Clinical Practice

by Stephen Gascoigne


More than a dozen years ago, I could not work as a practitioner. I was burnt out and unable to listen to anyone about their health. It had become apparent over the previous year that I was losing patience with others' suffering. Whenever I asked someone how they were, a voice in my head was saying, 'Is that all?'. I told everyone I saw to take it easy, have more time off work and relax.

Eventually, I saw the light and listened to my own messages. I worked for an organic gardener for over 2 years whilst I looked after myself and listened to my own needs. When I began to practise again, with the immense benefit I received from taking Chinese herbs from my eventual herbal teacher, I realised how anxious I felt when taking a case. Sitting in a room with a stranger listening to their stories is a great act of trust on their part but also a very challenging process for us as practitioners. We come face to face with human suffering in all its shapes and forms. How can we sit and be present whilst we listen, whilst we truly listen? Interestingly, my first patient after this absence from practice was a medical practitioner who had burnt out and could no longer work how our patterns follow us and seek us out!

Subhuti Dharmananda wrote in his column in Chinese Medicine Times last month about the importance of education and training when we practice Chinese medicine. I thoroughly endorse his thoughts about learning and the need for us to continue this throughout our professional careers. When I trained in acupuncture in Shanghai in 1985, I met a doctor who had qualified in 1944 when the Japanese were still occupying the city. I asked him how we could be better practitioners and he emphasised the need for continuing study. His regret at that time was that he could not study as much as he wished due to his teaching commitments. This, from a man who, I am sure, had forgotten more than I will ever know about Chinese medicine.

However, to be an effective practitioner, we also need other skills. How do we sit with another person and listen with open hearts to their stories? I am constantly humbled by what people tell me about their lives and their experiences. So, when we piece together a Chinese medical diagnosis from what we are told, we need to depend on our knowledge of Chinese medicine but we also need to 'see' the case clearly. I often find, both with myself and on talking to other professionals, that what may prevent us from making an accurate diagnosis and treatment plan is ourselves. If we are over-involved with the patient's story, or conversely over-detached, then we can miss the main point of the case.

It is in such circumstances that talking with other practitioners can be very helpful in defining the essence of the case and what needs to be treated. We hear a lot these days about continuing education and an important aspect of this is continuing supervision and discussion with our peers. When we see a patient, we need to be able to distil the essential points and present these to others so that we can discuss the diagnosis and treatment principles.

Have you ever looked back over clinical notes that you have made months or years previously? This is a useful, if not always comfortable, exercise. I find that when I re-read notes I can find startling discrepancies between the case and my subsequent diagnosis or between the diagnosis and my treatment. In the most glaring examples, I can find that there is no diagnosis at all and certainly no treatment principles! Bob Flaws talks about this in his learning programme, Sticking to the Point and has some very relevant points to make about constructing a diagnosis. It is absolutely necessary to explicitly state the diagnosis and treatment principles.

If we do not know where we are going, we cannot decide if we get there, or not. Of course, treatment principles can be amended in the light of further questioning and response to treatment so they are not necessarily fixed and unchanging. However, we do need them. When I teach seminars and we discuss cases in the class, the case may be presented very well yet can lead directly into which points are used or which herbs were prescribed. Now, clearly for a practitioner to decide on a particular set of points or herbal prescription, there has to be some process leading to this. Yet, there can be a certain reluctance to explicitly state it. Why is this? Perhaps we are anxious about whether we have found the 'right' answer, perhaps we are fearful of doing the 'wrong' thing, there may be some degree of embarrassment about sticking our neck out.

Whatever the reason, such feelings can only get in the way of benefiting the patient. Just as simply taking a case can lead to difficult feelings, writing it down clearly with stated objectives can be quite daunting. I believe that the more we focus on the patient and what benefits they can attain from treatment, then the less likely we are to become over-concerned with our own difficulties. This is not to say that we should ignore what is happening with ourselves. It is only by meeting our own needs whilst we are helping others, can we truly be of benefit.

Do you remember when you were first starting out in practice? It seemed impossible to be able to take a case, ask all the questions that you had in your head from lectures about case-taking, decide on a diagnosis, work out how to treat the patient and then determine what points or herbs to use. It was all too much. On top of that, the patient would often just not answer in the way that helped you write things down or would skip from topic to topic! This is why we have a structure to our work which helps guide us towards the diagnosis.

I would encourage all practitioners to consider their clinical notes to be a living, breathing document. This is particularly true regarding on-going treatment principles, prescribed drug medication and progress of the case. It is possible that we can lose track of the focus of the case when patients come for a prolonged length of time. It is helpful to have a summary on one page to refer to regularly which contains the salient points. In addition, the more we can freely share information about cases, the more we can support our own education and that of our peers. It is the application of Chinese medicine which is the whole point of our practice. Case notes provide us with a wealth of experience to call on.

So, to summarise the main points:

  • Write case notes clearly, legibly and logically
  • Be brave, make a diagnosis!
  • Draw up treatment principles
  • Determine acupuncture and/or herbal treatment
  • Monitor carefully over the ensuing weeks and months and modify treatment as necessary
  • Review regularly with the patient
  • Consider supervision or discussing cases with colleagues always ask for permission
  • Contribute cases to professional websites and journals always ask for permission

    Biography

    Stephen Gascoigne qualified in medicine in 1976 in Liverpool, UK and worked for 6 years in hospital and general practice. Stephen trained in acupuncture in China and subsequently in Chinese herbal medicine in London with the esteemed Vietnamese practitioner, Tinh Thong Nguyen. Stephen is the author of The Chinese Way to Health (Connections, 2000), an introduction to Chinese medicine and its methods for the general public and two textbooks for students and practitioners of holistic medicine - The Clinical Medicine Guide (Jigme Press, 2001) and The Prescribed Drug Guide (Jigme Press, 2003).
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