I’d like to go back over Fall term 2007 and distill what I feel to be the essence of what I learned in each course or clinic shift. It’s really fascinating to me how full of importance every single class turns out to be, regardless of my feeling of any one class at the onset. Over time this has taught me to be utterly open to the content of every course, the offerings of every teacher.
At NCNM, we begin our clinical education working in the Chinese herbal medicinary, and then graduate to Observation shifts, finally moving on to Internship the summer of our third year. Observation shifts are well named – mostly you watch. To some this may sound boring, but it is anything but.
Trying to follow the doctor’s reasoning, observing the minute action of fingers on the pulse, the flashes of understanding as the patient reveals some seemingly minor detail… it’s all so valuable. We are able to take the pulse and look at the tongue, and with some doctors we are able to ask questions of our own. Some doctors have students remove needles or do some of the less intrusive therapies, like indirect moxibustion. During the “down time” when patients are lying with their needles inserted, some doctors will teach in quite a formal way, others simply take questions, still others like to joke around and get to know their students. We are in Observation for two years, beginning in the second year.
This term, I had the distinct pleasure of being one of four students on Arnaud Versluy’s Observation II shift. I have been on three other observation shifts so far, all of them were wonderful learning experiences and each so unique! However, Arnaud’s shift was a different animal altogether. I’m not sure if this is just because of something inherent in Arnaud or if it is because of my deep resonance with his basic medical philosophy and enjoyment of our interactions – either way, I learned so much on this shift I wish I could repeat it for my remaining Observation shifts!
All of our doctors use the pulse in their diagnosis, but none so far have done so in such detail as Arnaud did this term. This may be due to the fact that he is a scholar and clinician in the Shang Han Lun tradition and in this school the pulse is emphasized. We began to learn a whole Shang Han Lun based pulse system, but really had to piece things together for ourselves. I believe he reveals more about this system in his mentorship tutorial, which is a fourth year opportunity.
From what I can tell, the system has similarities to that espoused in the Nan Jing especially in terms of pulse positions and incorporates a system of formula differentiation as distilled from the Shang Han Lun text. The idea is to learn the pulses and their correspondences so well that as soon as you feel a pulse, you prescribe a formula without much question. There are, of course, exceptions to this rule – but our trust in the pulse should be above our trust in the patient’s ability to fully articulate their pathological process.
This makes sense to me, above all, because of my own experience as a patient. It is rare that I can tell a doctor “what’s wrong” and while I can sometimes articulate very strange, and very diagnostically helpful symptoms – most of the time, I just don’t feel right. 😀
We also learned some basic pulse taking mechanics. It’s funny, because for all that we learned pulse qualities and the history of the view of pulse positions – we never learned “how to take a pulse” in any systematic way. Sometimes these basics get lost in the shuffle, I suppose. Arnaud gave us those basics on shift and I can tell you that my ability to learn from each pulse I take increased immeasurably.
Modular character of classical formulas
Arnaud is a formula guy, first and foremost. His point selections are intriguing, but it is in the realm of formulas that his brilliance is clearest to see. The easiest way to get him to talk a blue streak was to ask an insightful, but simple, question about a particular formula or formula modification. I’m sad to say that I probably didn’t take enough advantage of this resource – but when I did, the results were both deep and broad.
What I learned most was that the nature of classical (or canonical, as he likes to say) Chinese herbal formulas are exceedingly modular. What this means is that if you take half a dozen of the most used Shang Han formulas you will see numerous overlaps that make it simple to combine formulas without adding too many ingredients or making the formula too big.
This creates an extremely wide therapeutic output with just a small number of different herbs. It also means that the dosages and combinations in classical formulas are EXTREMELY tight. If there are 9 grams of Gui Zhi and 9 grams of Bai Shao in a formula, changing one of those dosages to 6 grams produces an entirely different effect. So, the practice of willy nilly modifying formulas based on wanting “a little more of this and a little less of that” probably isn’t a great idea.
Thinking about formulas this way has completely changed the way I study them. Instead of looking at formulas in relative isolation or placed in arbitrary categories (as found in most formula text books) I look at formulas as in relationship with one another. All of the formulas that contain a similar ratio of two herbs are going to be related in some deep way. This allows me to more fully understand the function of the formulas and be more effective with them in clinic.
Practically, whenever I learn a new formula, I spend some time searching for related formulas usually using electronic resources I have created myself. Then I read all I can about these related formulas, particularly anything included in the Classical texts. I seek to comprehend the similarities and differences. In some cases, I have also looked at all formulas with a particular two or three herb combination, regardless of dosage. This is also instructive.
Learning to ask good questions
As I’ve already mentioned, we usually got the most out of shift when we were brave enough to ask bold, yet succinct, questions. I tend not to speak up in academic group situations. Because of the rambling and pointless nature of some questions asked in many classes (Chinese medicine or not) I tend to wait until I have a truly important, well-informed and brief question to ask of a professor before I’m willing to put myself out there.
However, I know that this policy has probably negatively impacted my educational experience in some small ways. My academic relationship with Arnaud is helping me to get better at quickly coming up with relevant and insightful questions. I hope this skill continues to develop.
In sum, my term with Dr. Versluys was quite enriching. I’d be interested to hear the stories of other people, even in other schools, about their early clinical experiences. Any disasters? Any moments of earth-shattering insight? Let us know in the comments.