Seeking Patterns of Health

Will the best medic please stand up?

2005-01-14T13:39:00.000+11:00

It's easy to start believing that you're the best kind of medic there is when you slog through the hardships of your study and have those definitive experiences.

I remember one of the lecturers saying, "You guys will be the last resort for many of your patients. They'll have been to see three different GPs, a chiropractor, a homeopath, someone will have put them on some weird diet, and then they'll come to you, after everything else has failed. You'll get the most difficult cases out there - and if you pay attention, you'll be able to help them." Or something like that.

Then I looked around the room at the other first-year students and noticed that our average age was about thirty and that I was in my late twenties. "We've got life experience," I told myself. "What does someone who's never been outside a medical career know about the pressures the rest of the world faces? We know what it's like to be a patient, struggling with a doctor who treats you like an idiot - we're not going to fall into that trap."

There's nothing like a multidisciplinary environment to teach a little humility. The paramedics have an ECG trace on their noticeboard that they're supposed to decipher - I know enough to know that a healthy person doesn't produce that kind of trace, but no more than that. I discover that their practical test consists of walking into the prac lab and then 'handling it'. They don't even get told how many casualties will be there in advance - just like they won't know in real life.

A homeopath (one of those quacks) chats to me over lunch and takes a deep look into my eyes - the tiny lesions on my iris suggest chest pain to him, do I have any? Yes I do.

The thing we don't have at my campus is physicians, so it's easy to maintain a sense of superiority there. Until you start reading their blogs, anyway. It turns out that they're not robots following a rigid set of protocols after all. Their workloads are impossible - except for the fact that they make them possible somehow. And they're face-to-face with death, unlike folks like me who get the job of treating back pain that hasn't improved over five years, and isn't going anywhere soon.

As the senior lecturer said, "If I get hit by a car, don't take me to the Chinese medicine doctor, get me to a hospital! Over the months that follow, when I'm trying to rebuild my strength, then take me to the Chinese medicine doctor, so that I can recover more quickly."

Let's hear it for the best kind of medic - the one that helps their patient, whatever system of medicine they practice.

Pattern-Based Medicine?

2005-01-12T02:41:00.000+11:00

So what the hell is this 'pattern-based medicine' anyway? It is, like many Chinese ideas, something very difficult to put into words. But I'll try. Perhaps the easiest way is by contrasting it against 'disease-based medicine'.

Disease-based medicine is a medicine that diagnoses a disease and then treats or cures that disease. For instance, a patient might be diagnosed with pneumonia, and the pneumonia is then cured using antibiotics that kill the pneumococcal bacteria. Disease-based medicine can be said to be 'yang' in nature - it is direct, forceful, somewhat violent, and produces a swift result.

Pattern-based medicine is 'yin' in nature - indirect, slippery, gentle, and slow. Definitely not the method of choice if you're drowing from fluid accumulating in your lungs and you've not got long to live! But when you're feeling 'not quite right' and no single cause can be identified, this is when pattern-based medicine shines.

(At this point, I need to point out that sometimes strange things happen - sometimes disease-based medicine is very effective in treating mild, chronic complaints. Pattern-based medicine occasionally produces powerful benefits in acute illnesses. Biology is such a complicated field that few rules exist without exceptions.)

In pattern-based medicine, a patient's signs and symptoms are grouped according to certain themes. For example, fever, red skin, red eyes, insomnia, irritability, dry skin, and dark urine are all among the signs and symptoms that indicate 'heat'. By contrast, a runny nose, large urine output, mental sluggishness and excess body weight are among the signs that indicate 'dampness'. A patient with a mixture of signs from both lists might well be described as having a 'damp heat pattern'.

(Note that physical and mental indicators are mixed together in these lists, and that not all of the items on each list are things one might automatically associate with concepts of 'heat' or 'damp'.)

Having determined the particular pattern of someone's illness (which could be as simple as 'rising heat' or as complex as 'phlegm-heat obstructing the orifices with cold below, heat above and wind attacking the upper organs with failures of the digestive and nervous systems', which is why we go to school to learn the difference), the pattern-based therapist determines a counter-pattern, or 'treatment principle', such as 'cool heat' or 'drain damp'.

For example, let us assume that a patient presents with a mild, congested headache and upset stomach. Both of these symptoms can be described in terms of things (stomach contents and sinus fluids) going up when they are supposed to go down. And acupuncture point LI4 is good for sending things down, which is why you use it for congested headaches and nausea, but not on pregnant women (unless you're trying to induce labour).

In a more complex case, multiple acupuncture points and/or herbs can be combined to provide a tailored combination that address all of a patient's symptoms at once.

Somehow, I'm not satisfied that I've explained the difference between pattern-based and disease-based medicine approaches, let me try another angle.

Disease-based medicine is based on a 'cause and effect' model. To return to pneumonia, a bacterium causes an accumulation of fluid in the lung which inhibits breathing, which eventually results in death if the disease is not treated. Eliminating the cause (the bacterium) eliminates the effect (life-threatening disease).

Pattern-based medicine is based on a 'mutual causation' model. Imagine a stressed-out worker with insomnia, high blood pressure, irritability and a tendency to brood over the problems they're having at work. The brooding over problems causes the insomnia, which causes a lack of sleep, which makes the patient irritable, which means they have outbursts at work, which means they're on edge all the time (driving up their blood pressure), which makes them brood about their problems when they get home - this causes insomnia... (repeat as required). The pattern-based therapy makes a simultaneous assault on all of these symptoms at once.

Now, you could treat the stressed-out worker with a disease model, and you could treat the pneumonia with a pattern model, but neither of these solutions would be ideal. In the case of the pneumonia, a single cause can be found and elminated - and it needs to be done quickly if the patient's life is to be preserved.

Let's now treat our stressed-out worker with some medication to help them sleep, on the assumption that the sleep deficit is the root cause of their problem. Sleepers in a high enough dose to overcome the psychological effects are problematic, since they introduce the possibility of overdose or dependancy. Then there's the possibility of simply oversleeping, which stands a good chance of driving up the anxiety levels and defeating the whole exercise. The power of the disease-based approach works against itself here, threatening to upset the balance more than the original illness. A gentle approach over multiple fronts is preferred over a powerful strike at a key location.

So yeah, pattern-based medicine and disease-based medicine. Like yin and yang, they complement each other very nicely if they can learn to work together.

What I hope to achieve

2005-01-12T01:54:00.000+11:00

I blog about my personal life elsewhere, so this blog here isn't really about personal growth or having somewhere to talk about having a bad day, or about having a good day (I have those).

Something really valuable is happening with medical blogs - people like The Cheerful Oncologist are posting wise things that remind me that alternative medicine doesn't have a monopoly on compassion. Others like Chronicles of a Medical Madhouse are much more of an adventure through bureacracy and overwork in the hospital system. Either way (and in between), there's a growth of information about medicine and the people who practice it. I want to be a part of that.

Also, I think there's a chance that I can be part of opening a dialogue between Chinese and Western medicine. It's a dialogue that's needed by both sides, but especially by patients.

Part of that dialogue means advocacy on issues like clinical trials - both the need for Chinese medics to lift their game in that area, and for Western medics to realize that the double-blind placebo is not always the best trial methodology. I'd like to be in a position to claim some credit when pragmatic trials take over from placebo trials. I believe that has to happen for both sides of medicine to improve their credibility.

I would like to think that Western medicine might add 'pattern diagnosis' to its repertoire, or at least to develop an appreciation of it and include in their protocols a point where patients are referred to pattern-based (as opposed to disease-based) therapist. Perhaps I can engender interest on the part of my Western medical colleagues.

And, inevitably, I will have weaknesses in my thinking, in my argument. I will be reminded that the Western medics know more than anyone else about how to save lives. And that will be useful for me too.