A Clinician’s Inquiry: The Unspoken Words

A Discussion of Didactic Inquiry

A CAPSTONE
SUBMITTED TO THE DAOM PROGRAM
AND THE COMMITTEE ON DOCTORAL STUDIES
OF FIVE BRANCHES UNIVERSITY
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTORATE IN ACUPUNCTURE AND ORIENTAL MEDICINE

By
Doc Mitchell L.Ac. Five Branches University August 2010

Preface

The process of writing this paper has been long in the unfolding, gleaned from thousands of clinical visits and consideration of what is worth adding to the massive volume of literature regarding medicine. I have found myself asking, “Is there anything I can add to the missives of clinicians?” After lengthy clinical discussions I have come to study and reflect on the relationship I have found between the 21st century patient and the clinician of a very old tradition of medicine. It goes, perhaps without saying, that this is both a cultural and temporal phenomenon, one informed by modern western society and the drogue of clinical observations. It is not that modern humans differ greatly from their recent ancestors, as they don’t. While hunters and gatherers by design now occupy the city streets, drive automobiles and engage in activities much different from their ancestors, human biology is basically unchanged in the last 100,000 years. But as we have increasingly removed ourselves from the dominant paradigm of nature that has arguably informed the development of our processes, we have also perhaps lost an understanding of context.

Indeed many patients in the modern clinic have little relationship to the ancient tribal storytelling that provided the tapestry of an understanding that advocated integrity and functionality to one’s self, to the group, and to the supporting environment. While there is no shortage of information available today with all media, much is often presented in chaotic fashion and changing often depending on the current research. Patients I have met have remarkable ways of accumulating and stacking facts that bear little if any relation to the observable and consensual reality of nature, defined and exhibited by life in the forest, desert, or jungle, the paradigm that has shaped the genetic expression of our species. A failure to encounter this parsimonious fact leads perhaps to creative foolishness. I have often found myself comparing this process to someone who starts building a house from the second story to the foundation.

So this is a study of the story told. As this project has grown from the early notions through different iterations, it has changed. It has become more personal because that is what it is, a study of a clinician’s inquiry. As I have tried to squeeze any and all findings and discussions through the filter of other research papers I have come to what follows. Notions discussed and researched herein have been worked with patients and students in the classroom as well as long-suffering friends and of course my wife without whose loving and patient support this would not be possible. The paper itself was winnowed greatly through the editing commentary of my friend and writing mentor Mark Yoslow Ph.D. It is all work in progress. These are notes from the field, poems from the outer edges and utterances of the way home, all an inquiry of the human condition rooted in the clinic assay and defined by lenses of survival.

We are here as clinicians, those in direct contact with individuals in need, responders to the call of others. For some this is as a calling of deep personal significance and for others it is only as one who marks time, another the soldier in the trenches of healthcare with no larger calling than fate or a job. The response to disease and suffering is the most obvious reason; to help lessen pain, stop the progression of disease and dysfunction. Individuals have for millennia sought someone with special or studied talents to aid in

this process, the return to a state of integrity, however far that journey may take them. Some patients, beginning life, might benefit for decades from a simple act while others in their latter days, may benefit mere weeks, days or even hours.

What is the ground of organic process that roots the intentions of continuing, of surviving? What do we (or should we) as clinicians “point to” as the rest of the story in our medicinal machinations? What is this process? Is this even necessary? I think so.

I think so because I have seen people wake up from the process of disease cascade and take ownership of their lives and choose to seek architectural understanding of life’s organic and energetic paradigm. No longer only the recipients of medical care, they seek understanding that guides and informs their daily decisions and the principles of function and process that they can advocate.

It is this awakening that has intrigued me. It is this process in which the clinician plays the role of teacher and mentor as well as diagnostician and medical technician that I have found the pregnancy of the clinician’s role impacts long term outcomes for many patients. Without this relationship, life lived unskillfully invites decay with poor advocacies, the personal and social costs of which are enormous.

Table of Contents

Preface i

Abstract 1

Introduction 1

A Brief History 3

Literature 6

A Theory 8

Methods 9

Results and Discussion 10

Conclusions 15

References 20

Appendix: A Case Study I

History: I

Energy II

Emotions VI

Food IX

Summary X

Abstract

This study explores and unfolds elements critical to the core of the clinician/patient relationship and the language of intention in the diagnosis, treatment, and prevention of disease. The clinical relationship of this studied view of life and the rectifications of disease are rooted in the inquiry or assay of signs and symptoms with the patient. How might the detailed inquiry process of the Traditional Chinese Medicine (TCM) clinicians and their unique theoretical and historical view enhance this process? The filters and choice of language, values of inquiry, and the process of mentoring tacit understanding populate this educational terrain, all a challenge to clinicians in intending patient health.

Introduction

Although fate indeed informs the development of many illnesses in modern society, many are ostensibly wrought by behavioral choices, personal indulgences, and lack of education. Many find illness through misspent efforts, endorsing stress on underlying biological/energetic processes and terrain, as well as “inviting” exogenous pathogens. Others, regardless of their efforts, seem unable to extend their life one hour. Thousands upon thousands of conversations, inquiry of signs and symptoms, and the rigorous application of TCM diagnostic logic have framed the above issues in Didactic Inquiry, the inquiry as to status within a view of Nature’s unspoken terrain and processes.

Two decades of clinical practice and thousands of conversations encircling the process of inquiry unique to the TCM clinician and the intentions of return to wellness have wrought curiosity about relationship and conversation between the medically educated individual and the patient. I have called this Didactic Inquiry, a process of inquiry and tacit education enabled by repeated clinical visits. Didactic Inquiry is planted and cultivated via the lens of language and concept and rooted through repeated mentoring.

Medicine is the diagnosis, treatment and prevention of disease. The clinical relationship of this studied view of life and the rectifications of disease are rooted in the inquiry or assay of signs and symptoms with the patient. How might the detailed inquiry process of the Traditional Chinese Medicine (TCM) clinician and their unique theoretical and historical view enhance this process? What are the elements of this process? This is an exploration and unfolding of these elements critical to the core of the clinician/ patient relationship and the empowerment of the patient, a challenge to clinicians in their efforts to intend patient health with the communication of Nature’s terrain and its consequences according to the inherent logic of Chinese medicine.

Not unlike psychological counseling but more like tradecraft mentoring, the process of Didactic Inquiry seeks to engage patients in their own process of healing and living life skillfully and within the context of successful organic processes. The visit is not only prescriptive but also educational. Years of practitioner study and its benefits are applied

and shared as indicated in the context of the process of inquiry. Unlike much of modern medical practice wherein the average clinical visit is less than 15 minutes and less than thirty minutes per year average (Kaarlela, 2007), the overarching values of the TCM visit are contextual and behavioral, requiring deep inquisition and less reliance on lab work. While such deep inquiry is not a standard of practice per se, the ontology of the medicine invites such engagement.

The clinician of modern biomedicine is highly educated in chemistry, anatomy and physiology. The image of doctor as scientist dominates the role and the modern clinical assessment is characterized mostly by a gathering of data that supports a biomedical diagnosis. Treatments are usually pharmaceutical substances or procedures, both increasingly expensive interventions. The context of many of these diseases has been unexplored behavioral choices. Patients approach doctors with health issues and are often prescribed medicinals or procedures to ameliorate their suffering. Office visits to the doctor consist of brief intake, review of pertinent studies, blood work, films, etc., and the prescription of procedure or medicinal. Little or no time is given to either discussion of issue nor the context of life that deeply affects vitality and health.

Allopathic clinicians often take little time in developing personal relationships with patients wherein fruitful discussions might help individuals develop an understanding of health, supportive behaviors, ideas for change, and the death process. Also, many modern practitioners of TCM have practices designed to see the maximum number of patients, either by choice, system designs, or poverty of resources, all leading to a greater emphasis on treatment procedure and prescription alone, emphasizing one of the opportunities available to the relationship. As such, medicine defined only as a culture of curing disease often fails to develop an understanding of context in patients that may add to their personal inquiry around health and longevity. One of the great ironies of modern scientific medicine is that the growth in cures for age-old scourges has been matched by the growth of long-term degenerative and chronic misfortunes. Not infrequently, the clinician is faced with issues of health, not random, but chosen, consciously or unconsciously, that result in a cascade of phenomena and end in expensive interventions. Even modern interventions suffer complications, as iatrogenesis itself has accounted for over 30% of all hospital admissions (Deborah C. Francis, 2005).

While the clinical assay is without question an information gathering process, it also infers context that informs values regarding behavioral choices. As any medicine is an applied philosophy that underpins diagnostic analysis, the clinical visit and inquiry is the portal of entry to the professional relationship that may define the initial path of return to health. From the beginning of inquiry through the logic of diagnosis, the TCM clinician teases apart the subtle signs in the patient’s tale that reveal his or her quality of life, understanding of energetic autopoiesis, i.e. the ability of an organism to self-organize and function in such a manner as to intend the integrity of health and homeostasis in the flux of life. This is the study of life stories that unfold with attention to the significance of process, the essentials of life, and its continuation.

The human story plays out in this narrative of survival, the continuation and prevailing of function, and the discussions of disease alone, without life, death and health, often fail in the development of comprehensive understanding. Lack of comprehension is often

accompanied by the physician’s assignment of corrective behavior and the expectation of rote compliance. Rules of health explicitly stated without engaging the tapestry of function, death, and disease do not provide or demonstrate context. Without a culture or tapestry of understanding, actions, however well intentioned, often do not succeed, or suffer the fate of unintended consequences. Bereft of support for sober inquiry and consideration, self destructive behaviors continue.

As the success of living is most often rooted in the intention of prevailing, a course of action is best rooted in an understanding of essential processes. Understanding is gained through observation, trial, and error. While the history of humans is replete with oral and written discussion of this context, modern medicine discusses disease and treatment, neglecting a valuable invitation to delve into discussion of context. The presumption that all disease begins with manifestation leads much research to the treatment of disease only, and the inquiry as to cause remains impoverished. The clinical visit can be the entry into such a dialogue for the clinician. The patient visit and the clinician’s inquiry invoke the invitation to the clinician to participate in the outcome of the patient’s destiny. Such inquiry can offer insight, indeed a road map for participation in the journey back to health.

This argument advocates using clinical inquiry to discuss the implications of the patient making better choices and the implications of these choices to promote health, wellness, and survival, as well as a diagnosis that possibly requires prescription of technique and medicinals. How might this invitation to participate in a patient’s life help invoke the process of signification to the development of enhanced living skills and resultant health, vigor, and longevity? How might the view, the language, and the inquiry of Chinese medicine add to the development of tacit knowledge and heuristic learning on the part of the patient within this process? How might the Didactic Inquiry of the Chinese scholar clinician engage consideration of the patient’s own autopoiesis?

What does this process look like: the development of tacit understanding, the personalized relationship with the intimacies of one’s own processes, and the nature of survivable and sustainable patterns of behavior that advocate for these processes? What is this road map of sorts for heuristic learning or learning by experimentation with these rules of thumb. What are discernable qualities of “sense-scape” and values that provide navigational cues within the values of thriving longevity? What is this context where the clinician takes the role of mentor to help in the development of these skills?

A Brief History

Medicine, or the study of methods of rectification, and the tradition of doctor/ healer dates from antiquity, probably well into the Neolithic era, where the shaman engaged a patient’s fate with intention, using charms, spells and medicinals. The Cannon of Medicine compiled in 1025 by Ibn Sina, influenced mainstream medical practice through the 18th century. He wrote, "Medicine is the science by which we learn the various states of the body; in health, when not in health; the means by which health is likely to be lost; and, when lost, is likely to be restored. (Wikipedia, 2010)

The modern model of medical education was influenced greatly by William Osler (July 12, 1849 – December 29, 1919) at Johns Hopkins medical school, whose advocacy of clinical rounds in the medical education process helped forge a greater reliance on patient-centered medicine. Noted for his humanism and his patient centered approach to medicine he said “doctors should care more about the individual than the disease and that "If you listen carefully to the patient they will tell you the diagnosis"(FRCP, 2005). “For him, medicine was 'an old art [that]... must be absorbed in the new science,” (FRCP, 2005) and that “One of the first duties of the physician is to educate the masses not to take medicine” (Robert Bennett Bean, 1961 p. 105).

The Flexner report of 1910 basically set the standards for medical education and practice in the US. With the report came the implicit advocacy of the biomedical model that persists today. Flexner “...clearly doubted the scientific validity of all forms of medicine other than biomedicine...A few schools resisted for a time, but eventually all complied with the report or shut their doors” (Wikipedia Foundation, nc., 2008). This marrige of the biomedical model to medicine persists today.

This biomedical model, reductionist as it is, has gained dominance in modern civilization as is evidenced by the healthcare and pharmaceutical industries, although some medical anthropologists question the underpinnings of its dominance: Is it truly that efficacious or have competing models have been successfully undermined and destabilized by economic and political forces? Recently, there has been a resurgence of interest in “natural” medicines, as is evidenced by the National Institute of Health’s embrace of research on “evidence based medicines” and Complimentary and Alternative Medicines . However, the clinical algorithm of research for evidence-based medicine favors the Randomized Controlled Trial (RCT) paradigm of biomedical research, and has been criticized for its narrow view.

Specialization dominates the current practice of modern medicine.

Of the three countries, Australia has the greatest number of primary care physicians per 100,000 population (112) and the largest proportion (56 percent) trained in primary care specialties. The US percentage is 36 percent, which Bindman notes is “a relatively low number that most likely contributes to the lower rates of exposure to primary care in the US.” (Kaarlela, 2007)

The average American spends a total of about 30 minutes a year with a primary care physician in a system that is less comprehensive than that of Australia or New Zealand, according to a new study comparing primary care practice in the three countries. (Kaarlela, 2007)

This clinical model, obviously, leaves little time for educational strategies. Nor does it offer incentive to do any more inquiry beyond justifying prescription. Currently, significant numbers of individuals die with diseases related to behavioral choices (Centers for Disease Control and Prevention, 2010), ignoring wholesome behaviors, yet the current model of medicine is continually supported, and both heavily influenced, by lobbyists at the political level, and biomedical research at the pharmaceutical level (Eggen, 2009). Clearly, in this model, education is not a source of income.

Modern clinical medicine has developed around the biomedical scientific method, wherein results are testable and reproducible, i.e., standardized. Doctors are trained as scientists, versed in this ideology of facts, replete with explicit language to describe the world in scientific terms. The clinical model and algorithm of diagnosis and treatment are based on the assessment of data pertinent to this biomedical model to develop diagnoses and prescriptions for the prevention and treatment of disease. The continued development of this model has increasingly become dependent on pharmaceuticals, medical equipment, and biotechnology.

Yet with all the technological advancement of modern science “The US pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy” (Health care in the United States, 2010). The United States life expectancy lags 42nd in the world, after most rich nations ”(Health care in the United States, 2010). Access to human behaviors is limited to facts and instructions. RCT (Wikipedia, 2010) dominate modern research to prove “facts.” Such applied research benefits the development of products, devices, and procedures to be applied to sickness, but have done little to encourage people in their understanding of living well, as is evidenced by the current swelling of behavioral based diseases: diabetes, AIDS, some forms of cancer, and iatrogenic diseases amongst others.

Does the ongoing discussion of the doctor and patient relationship need to be seen in the greater context of the human condition? What does it look like to involve the patient in the process of inquiry, and what are the elements involved? What is the relevance of the relationship of the clinician to the patient as a teacher, mentor, or one who might help the patient in the development of sober understanding, skillfully engaging the flux of life? How much discussion is given to the relationship between a concerned clinician and the patient’s understanding of life, and his or her development of heuristic life skills? The physician as scientist alone stands to deeply understand a portion of a patient’s reality, but how equipped is he or she to take advantage of the opportunity presented by the clinical visit for helping the patient develop heuristic life skills beyond fulfilling a prescription or submitting to a procedure? The detailed and highly personal inquiry of TCM clinicians, and their particular language and philosophical underpinnings, have been widely discussed in historical texts and have clearly stated values regarding the context of longevity.

How might this invitation to participate in a patient’s life help invoke the process of signification for the development of enhanced living skills and resultant health, vigor and longevity? How might the view, the language, and the inquiry of Chinese medicine add to the development of tacit knowledge and heuristic skills on the part of the patient within this process? How might the Didactic Inquiry of the Chinese scholar clinician engage consideration of the patient’s own autopoiesis? What does this process look like?

The discussion Didactic Inquiry calls for an understanding of language and concept, linguistics, psychological resonance and development, educational theory and mentoring, the values of Chinese medicine, organic processes, the values of sober inquiry, congruency of intentions, and consideration of consequences.

Literature

The conceptual framework of Didactic Inquiry draws from the realities of the clinical relationship and vocabulary. The language of the clinical assay serves to orient attentions. In the case of TCM inquiry the selection of language contains words and concepts peculiar to the Chinese language and has a distinct impact on the criteria of observation. In A Survey of Traditional Chinese Medicine the authors note “Chinese is the maternal language of acupuncture. This solid and massive fact should preoccupy every practitioner and teacher of acupuncture.” (Larre, Schatz, & Rochat de la Valle, 1986) (p. 31). A consideration of the potential impacts of the phenomenological nature of the Chinese language versus the more abstract nature of the Indo European language group might be seen reflected in the works of Benjamin Lee Whorf whose collection of essays entitled Language, Thought and Reality: Selected Writings (Whorf, 1956) delves into discussion of the conceptual differences of language. While his works stress the linguistic and conceptual differences of the Native American Hopi people and native English speakers, his linguistic hypothesis addresses the importance and influence of lenses of language and concepts, and the subsequent understanding of phenomena. This introduces the notions of linguistic filters, those that shape view and organization of thoughts, thus shaping decisions.

Guy Deutscher (Deutscher, Through the Language Glass: Why the World Looks Different in Other Languages, 2010) continues this discussion of linguistics with observations that, indeed, words and linguistic frameworks affect what we are compelled to account for within the context of a language.

The deliberateness of the clinical relationship generates a special resonance with personal inquiry within the context of unwinding personal narrative. The process of engaging these attentions of signification develops this resonance, which is discussed in the essay Intuitive inquiry: Interpreting objective and subjective data (Anderson Ph.D., 2000). While the topic of such inquiry by the traditional Chinese medical clinician is considered in the essay Medicine is Signification- Moving Towards Healing Power in the Chinese Medical Tradition (Schied & Bensky, 1998) the discussion of the methodology of Didactic Inquiry, put forward earlier, is informed by the lens of Heuristic Research: Design, methodology and applications (Moustakas, 1990). Underpinning this process as well is the understanding and development of tacit knowledge as discussed in Science, Faith and Society- A searching examination of the meaning and nature of scientific inquiry (Polanyi, 1964). The patient’s insight gained from repeated clinical visits is explored employing the educational theory of scaffolding drawn from the themes in The mind in society: The development of higher psychological processes (Vgotsky, 1978).

The interactive clinical inquiry itself is done against the tapestry of Chinese medical theory, its subsequent values and “statements of fact” that define the best clinical practices of Chinese medicine. Though briefly and incompletely stated here, they provide a modicum of landscape design to the discussion of the clinical relationship. Two thousand years of clinical literacy have produced, literally, thousands of texts, many dating from antiquity yet used currently in the modern clinic and in research. Of those thousands, a few stand out for their clarity reflecting issues of this inquiry including

Extra Treatises Based on Investigation & Inquiry (Dan-xi, 1994), Li Dong-yuan’s Treatise on the Spleen and Stomach (Pi Wei Lun) (Li, 1993).

From the perspective of this process, this engagement between clinician and patient invokes consideration of language, context, and relationship, and the scaffolding/ laddering of educational engagement leads to development of tacit understanding. These are lenses within which the phenomena of clinical inquiry are viewed.

Linguists have considered the relationship between language and world-view with diverse theories. Language connects, communicates, and organizes concepts and perceptions. This has been the object of much study from the linguistic positivists (Wittgenstein and Chomsky) to the linguistic relativists such as Whorf (and subsequent colleagues). While words as symbols can never accurately and totally encompass what is, they are often an important step in the initial cultivation of understanding the integrity of the narrative. These utterances are a rich medium of communication between patient and clinician, without which, much information is unavailable and communication is limited.

The TCM clinician’s bracketed relationship with patients pertains to specific context and outcomes. Volker Schied Ph.D and Dan Bensky D.O discuss this in a journal article entitled Medicine is Signification - Moving Towards Healing Power in the Chinese Medical Tradition (Schied & Bensky, 1998). It is in this article that the discussion of Yì or the intention of the physician in classical times is applied to the clinical relationship. Schied and Bensky’s contribution involves studying “the all encompassing” to arrive at complete understanding” (Schied & Bensky, 1998). It is the discussion of Yi as a principle, which is applied in this paper to the development of Didactic Inquiry.

The process of repeated clinical visits and subsequent inquiries invokes consideration of educational theory. For the purpose of defining Didactic Inquiry the theories of educational scaffolding and mentoring put forward by Vgotsky demonstrate precisely that clinician/patient relationship. In his book The mind in society: The development of higher psychological processes (Vgotsky, 1978), the author maintains that learning is socially mediated and that cognitive development is first interpersonal (Vgotsky, 1978). This scaffolding of the interpersonal mentoring process as described by Vygotsky enables people to learn something for themselves. This is the development of personal problem solving, which is heuristic learning. It is in Heuristic Research: Design, methodology and Applications (Moustakas, 1990) that Clark Moustakas discusses the study of “knowing through participation” as a personal experience.

The resonance of this personal experience as explained by Rosemarie Anderson in Intuitive inquiry: Interpreting objective and subjective data is described as seeking “to provide an approach to research which systematically incorporates both objective and subjective knowledge through a step-by-step interpretive process, that is, cycles of interpretation which shapes the on-going inquiry” (Anderson Ph.D., 2000).

Michael Polanyi, in his work Science, Faith and Society- A searching examination of the meaning and nature of scientific inquiry (Polanyi, 1964) explains this systematic inquiry into both objective and subjective knowledge as the development of tacit knowledge. This is the range of conceptual and sensory information that can be brought to bear in an

attempt to make sense of something. Individuals who “participate” in the inquiry and assessment of the quality of their basic functioning are more likely to learn and thereby develop a tacit understanding of their health and thereby their choices may become more meaningful and skillful.

A Theory

Didactic Inquiry, a process of inquiry and tacit education toward the goal of vibrant health, is enabled by repeated clinical visits. It is planted via the lens of language and introspection, rooted in TCM concept, and cultivated through repeated mentoring. The impact of the clinician and patient relationship is replete with educational and mentoring opportunities within this process of Didactic Inquiry. The self-evident realities of biological processes -- the dependent variables -- that define wholesome and vital organic life are cast and viewed in the relationship between clinicians and patients -- the independent variables. This observed relationship between clinicians and patients is a phenomenon in itself and, in this paper, is described in the context of philosophical, linguistic, and psychological processes. From initial contact and treatment of disease and through deeper engagement of causal reflection between clinician and patient, the relationship evolves into a mentoring process of tacit understanding through heuristic learning.

Years of academic and clinical training educate the clinician in the matrices of life, the organic processes that describe and indeed define life. With emphasis only on the response to malfunctions, a pregnant opportunity is perhaps missed. A visit to the clinician is rooted in the sea of profound relationship; the implied permission of someone to touch a life with inquiry and effort. That point of contact, that fulcrum point of destiny begins and is rooted in the clinical assay. From the first patient visit, the entwinement, the resonant engagement of clinician and patient, spins a life, maybe two, in possible new directions. While it is true of many relationships, it is generally understood that this phenomenologically bracketed clinician/patient relationship infers a relationship of intention, specifically, the return to wellness. The skill of Didactic Inquiry springs from the pregnant opportunity within this relationship. Didactic Inquiry invests itself in the telling of a story or tale with the intention of educating the patient in both the context of the inner world (the human body) and the outer world (the way of nature) and explains the how of things. The how of this is shaded by the who of the patient and how he or she is doing life. The resonance of this inquiry uncovers the quality of processes in relation to this larger story of viability in life, and thereby places one on a map of organic survivability. In the case of Chinese medicine it is an energetic map, replete with methods of rectification.

Navigating this organic road map with heuristic learning, or learning by experimentation, is learning through participation within the integrity of natural function and developing skills that advocate for homeostasis and longevity. The result of this process is often the development of tacit understanding, the personalized relationship with the intimacies of one’s own processes and the nature of survivable and sustainable patterns of behavior that advocate for these processes. Within this larger understanding of how things work, both inner and outer, decisions made in support of these larger processes advocate for

that which is wholesome and functional, laying a base and foundation for greater viability and integrity.

It is in this context that the clinician takes the role of mentor, someone who can help in the development of these heuristic skills. The qualitative investigation into the process of Didactic Inquiry is best described as an exploration of the philosophical constructs that would lead to increased patient participation in his or her own health. It is access to the underlying intentions of behavior that drives decisions advocating for health or advocating for disease. This investigatory method and the inherent context of both the logic of TCM and the resonance of subjective inquiry can engage the patient in a process of developing heuristic skills and tacit understanding that enhance health and longevity.

Methods

The goal of any medical intervention is the restoration of health. The restoration and maintenance of health implies not only the return of internal homeostasis, but also the ability of an organism to negotiate that state in the context of external stressors such as competing life forces, including environmental, bacterial and emotional stressors. The clinical exam is an assay of functions and resources in the overriding relationship between homeostasis and competing life forces

Fieldwork is the heart of any research, and the heart of any clinician’s world is the clinical visit. A case study is the accumulation of questions and data and the evaluation of status. Pertinent to the exploration of Didactic Inquiry are the day-to-day notes. These are the notes and considerations, the people and their stories, upon which are layered lenses of inquiry based on observations of life poorly done or well done.

In this paper the case study is not the focus of inquiry. The case study provides context for discussing Didactic Inquiry in much the same way as three blind men describing an elephant. Without the elephant, there is no discussion. So it is not the case itself that is important, but how the case is approached by the clinician and patient. The weakness of this discussion is that we can lose our way, much like the three blind men, who are lost in subjective observation. The strength of case study discussion in the context of this paper is that it is an example that supplies a platform for observing the roles and processes of the clinician and patient as a phenomenon and not as an investigation into a particular disease or disorder. The phenomenon is one characterized by inquiry and mentoring of practical knowledge and heuristic learning. Validation of this phenomenological relationship develops with the physician’s role as mentor and the patient’s life outcomes. The goal is to have patients ask, “Have I nourished my destiny with my choices?”

The endgame of any medical research depends heavily on the case study. Here, the case study is a glimpse of organic terrain and pathology, form and function, and the tapestry of relationship seen through the eyes of the inquiring clinician. Chinese medicine is a medicine of strategies. Successful treatment often requires multiple visits, and, as such, offers opportunities for constructive conversations. Each visit provides opportunity for assessment, inventory, and discussion of concern, content, and context. This is to enlarge the gateway of information gathering to include the patient and his or her awareness

around assessing both internal sense-scape and external data. This internal inquiry, this tacit understanding, is a bridge that becomes the path (Dan-xi, 1994).

The case study is an opportunity to dissect and discuss questions of significance to the clinician and values inherent in the logic of TCM with regards to the health of a chosen patient. The clinical inquiry is constructed using the basic TCM verbal assessment. A series of questions limited to the traditional diagnostic method are asked. The case study format is a summation of a course of treatments compiled over a period of time (9/08- 4/10). A detailed inquiry is potentially instructive to both parties.

This study is a look at the process wherein the TCM clinician points to the significant and essential processes of life and mentors the development of personal inquiry for the patient who is willing to participate skillfully in their own health. This is done in language that is personal and invokes the personal sense-scape of the patient, reflecting accuracy in both subjective and objective realities. This conversation becomes the study.

Smelling, listening, inquiry, and palpation, the four methods of diagnosis in TCM inspection, (Wiseman & Feng, 1998) invoke the opportunity for this engaging conversation. All are assessments of status but the listening and inquiry portion involves deeper engagement in language with both clinician and patient. The analysis and assessment is the gathering and winnowing of the essential from the non-essential and framing it in the logic of TCM. This analysis of a patient’s status is done against the background of the quality and pattern of organic process and the motif of thriving survival. Questions from both clinician and patient help define the status of organic process. This reflects the conversation between clinician and patient in the context of relationships, that between the patient and herself (See Appendix- A Case Study), and that between the patient and the realities of the external world. This invokes the consideration of consequences of decision and ultimately, the influences upon destiny. The result is the case study.

This raw data contains chief complaint, patient history, diagnosis, both modern medical diagnosis and TCM, and discussion and engagement of the pertinent and significant facts surrounding the patient. This and its process are then discussed in relation to lenses of theory and analysis from literature as noted in the literature review section. There is no discussion about medicinals or procedures. It is all about conversations. Summary and conclusions follow.

Results and Discussion

The research resulted first in a case study with applicable data. It is a brief case study with particular time repeatedly given to discussions of significant facts which are narratives looking for the integrity and logic of life processes. In the study of this process, and the nature of this relationship, insights were found in the literature of TCM, psychology, linguistics, and natural sciences. The dialogue between clinician and patient encompasses all of this and more in its deeper relationship as it searches for integrity of understanding between the two participants and tacitly leaps beyond technique.

While dialog may be limited in therapeutic bandwidth, the process of Didactic Inquiry avails assay and engagement of the patient’s own resources. This is not about providing medicinals or techniques. It is about responsible and skillful engagement with a patient’s needs, informing them of organic context, cause, and effect: good decisions, good outcomes, bad decisions, bad outcomes. Ostensible limitations of a patient’s potential involve availability of food resources, physical limitations, and social context to name a few of many inhibitions to the (idealized) potential.

Confounding variables abound in any clinician-patient relationship. These often take the form of self-destructive or confusing choices on the part of the patient. Success of the process of Didactic Inquiry can be construed as a regular re-visitation, advocacy and the eventual skillful engagement of the significant processes of life function resulting in fewer self induced degradations. Addictions, deeply ingrained habits, some social constraints, or a general unwillingness of patient compliance, stand to confound the best of intentions. However limited this engagement, the education of both clinician and patient, Didactic Inquiry provides opportunities untapped in the current model of clinical inquiry.

This research supports an understanding of the difficulty in communicating the best possible life and health practices to patients, and the power of language to help or hinder the process. This leads to asking questions about the issues inherent in the language used by clinicians and to influence the most positive destiny for my patients. The answer is found in linguistics.

The study of anthropological linguistics invokes discussion of linguistic filters as described by Benjamin Lee Whorf in the collection of his essays entitled Language Thought and Reality (Whorf, 1956) where his analysis of the Hopi language reveals pertinent reflection on the nature of linguistic filters; that language itself colors and filters perception and thereby cognition. Different languages and vocabulary reveal cognitive opportunities and dismiss others. Terms and concepts inform choices.

Whorf’s views on linguistic relativity suggest this influence of language and vocabulary affects perception. Nature, phenomena, and the flux of impressions are organized by our minds, from which thought occurs (Whorf, 1956).

“We dissect nature along lines laid down by our native languages.” ...“We cut nature up, organize it into concepts, and ascribe significances...” As such “all observers are not led by the same physical evidence to the same picture of the universe, unless their linguistic backgrounds are similar.” (Whorf, 1956)

The choice of language and vocabulary influence perception and thereby participation in the inquiry is limited to constructs and categorizations of significance. Language is a pattern system through which nature is organized and analyzed. It provides filters that that allows us to notice or neglect phenomena and processes. This language of the inquiry informs the lens of narrative through which phenomena are organized and reasoning and intention are derived and directed.

Whorf’s (1956) contention that language provides filters through which we perceive and organize phenomena and experiences is perhaps observable in the understanding and

expression of Qi 氣, while having no concrete correlate in English, is perceivable and demonstrable in experience. Naming and pointing to Qi (as an inquiry into a significant function) and thereby compelling accountability to that process, invokes the perception and understanding to the intentionality of one’s engagement in that process. (See appendix) We image the world in language and sense-scape. The understanding of this underlying field of vitality (Qi) and its corresponding qualities is without peer in the English language yet Qi both instructs and responds to engagement. With training the sense-scape if Qi is perceivable. The deliberate engagement of this internal assessment of quantity and quality, as reflected in the clinical assay, leads to understanding and participation in the very basics of life, that of organic process and its vitality. Deutscher writes,

“in the last few years, new research has revealed that when we learn our mother tongue, we do after all acquire certain habits of thought that shape our experience in significant and often surprising ways... If different languages influence our minds in different ways, this is not because of what our language allows us to think but rather because of what it habitually obliges us to think about.” (Deutscher, Does Your Language Shape How You Think, 2010)

Developed habituation and orientation to functional concepts of biological processes, both internal and external, invites eventual personal accountably and integrity of attentions, decisions and actions. He continues, “When your language routinely obliges you to specify certain types of information, it forces you to be attentive to certain details in the world and to certain aspects of experience that speakers of other languages may not be required to think about all the time” (Deutscher, Does Your Language Shape How You Think, 2010).

The pointing to significant organic process with assay, description of, and engagement of intention, patterns perception to the concreted realities of the necessary rather than the fanciful. Consequences of behavior become visible. Exploration of decision and consequence gain currency in the world of the experienced. This becomes the basis for decisions leading to favorable outcomes, i.e., longevity and health. It is in this view that language and words serve not only as a way to voice ideas. They also provide filters or lenses by which the perception of phenomena is filtered by an individual or culture. Says Larre

Modern western languages, known for their clarity and precision, deal with global abstractions or universal expressions with considerable virtuosity. While able to present an impressive array of such generalized ideas, these languages necessarily impoverish (by over- simplifying them) the realities they seek to present. The Chinese classical language is capable of defining reality with a precision that is both concrete and general. Chinese is phenomenological; it pictures what is (Larre, Schatz, & Rochat de la Valle, 1986), (p. 13).

He also notes, “It is not simply the use of needles and moxa which makes Chinese medicine so unique. [...] The western physician must understand that the Chinese

mentality and language are the two realities influencing the concept and the workings of acupuncture” (Larre, Schatz, & Rochat de la Valle, 1986) (p. 31).

The use of language, and the choices of concepts, impacts attentions, considerations, and decisions. “’Languaging’, as Maturana occasionally explains, serves, among other things, to orient. By this he means directing the attention and, consequently, the individual experience of others, which is a way to foster the development of ‘consensual domains’ which, in turn, are the prerequisite for the development of language” (Glasersfeld, 2010).

This gradual effect on human understanding as it responds to the world via its understanding patterns affects neurology. "The plastic splendor of the nervous system does not lie in its production of 'engrams' or representations of things in the world; rather, it lies in its continuous transformation in line with transformations of the environment as a result of how each interaction affects it" (Maturana & Varela, 1987) (p. 170).
The consensual domain becomes the framework of the clinical inquiry; the assessment of significant biological and energetic process. These attentions to biological processes, in the context of personal survival, transform and patterns behavior.

The what, the choice of language, perhaps influences the how of the communication between the clinician and patient. The clinician thereby shapes the language and points to significant issues consciously or unconsciously by his choice of words. Medicine is thereby signification or attenuation to the significant. The uses of terms abstract to the patient’s direct experiences such as statistical values and facts outside of the foundation of the patient’s learning offer little resonance as many are not experiential and explicit directions and goals can become distant to the day to day.

Scheid and Bensky describe this definition of medicine as Yi (from yï zhê yì yê) meaning “medicine is intention” (Schied & Bensky, 1998). They continue to say

Yì or intention here seems to refer to that which the physician desires and consciously conceives of, that which he wills, but also to that which comes about through a kind of focusing of consciousness. The present best guess as to the original meaning of this word is that it referred to what goes on in ones mind before speaking (Schied & Bensky, 1998)

This also reflects on the development of personal cultivation, the development of integrity and “self fulfilling forecasting”. (Schied & Bensky, 1998) Mortality is often the catalyst or grandmother of this process, without which, there is often no invitation to engagement.

The bracketing of the clinical visit is that of “health and disease” and the assessment of the quality and integrity of organic processes is in the context of life’s challenges. The word integrity stems from the Latin adjective integer (whole, complete). The Chinese word Li 理 is sometimes translated as the Confucian concept of Virtue, but to the Neo- Confucianist or Taoist it was often translated as Integrity. Integrity as value invites accountability. Essential conflict and discrepancy between integrity of response and challenge leads to struggle, dysfunction, and disease. Signification in this context is the deliberate pointing to or “bracketing” of phenomena within the context of organic

process, the intention of survival, and the skillful response to that challenge e.g. “What goes on in the mind before speaking” (Schied & Bensky, 1998) Conversations are informed by considerations of the significance of these organic processes. The process of signification is the pointing to these assemblage points of organic process that define vitality and life. Perversions of this organic and functional vitality are the substrate of much disease and indeed much self-inflicted injury.

The overarching architecture of this process is the repeated visits of engagement to the clinician. The repeated engagements inherent and necessary in the visit to either acupuncturist or clinical herbalist invite the potential for education. Both require continuing reassessment of pattern presentation and the tailoring of therapy specific to presenting phenomena. In Vygotsky’s social cultural model he asserts that all learning is socially mediated, (Vgotsky, 1978) and that with appropriate scaffolding of education and mentoring by a more experienced peer, cognitive development occurs. The area of influence is the zone of proximal development, which is the difference between what a learner can do without help and what he or she can do with help. This is first interpersonal and refers to “instruction, assistance, and support and is most effective when it involves modeling by an appropriate peer, providing cues, and encouraging the child to think about alternative plans of action”(Vgotsky, 1978).

The scaffolding of educational knowledge is best supported by a more experienced peer and is the initial basis of cognitive development (Vgotsky, 1978). The interpersonal relationship of mentoring and the assistance of providing cues encourage the development of alternative and supportive models of behavior. This process of repeated observation and interpretation of phenomena leads to tacit knowledge (Polanyi, 1964).

The re-visitation of the clinical inquiry with Didactic Inquiry is the basis of mentoring the patient. Initially the clinician leads the inquiry and instruction, and “models appropriate questions” (Vgotsky, 1978) to foster the patient’s understanding of the essential processes and consequences of behavior. As the process gradually develops, the students “take over the teacher’s role” (Vgotsky, 1978). It is in this relationship that it is often better to ultimately emphasize the patient’s ability to solve problems rather than assess the bulk of their knowledge specific to medicine. The education of both organic process and mentoring of life well lived invoke potential for the development of a life lived skillfully.

This inquiry “seeks to provide an approach to [inquiry and] research which systematically incorporates both objective and subjective knowledge through a step-by-step interpretive process, that is cycles of interpretation which shape the on-going inquiry” (Anderson Ph.D., 2000). In Didactic Inquiry, patients’ self-knowledge of their own sense-scape in the context of organic process has value. As Anderson writes “Valuing rigor, precision, and clarity does not exempt us from providing descriptions of human experiences which claim the full domain of being human, including experiences generally thought of as spiritual and mystical” (Anderson Ph.D., 2000). This process invites patients to speak from their own experience and in the context of their own knowledge and sense-scape. It also systematically challenges patients’ understanding, decisions, and their evaluation of the consequences of their behaviors. This helps to develop more skillful responses to environmental challenges with their newfound understanding. By employing these experiences and lenses of personal experience a vantage point is gained that allows

patients “to see more subtly into the particular nature of the phenomenon studied in a deeply connected way” (Anderson Ph.D., 2000).

This concept of knowing through participation is at the core of heuristic inquiry (Moustakas, 1990). The initial entry into the process of clinical inquiry is generally pain or dysfunction that drives or initially motivates the patient visit. This begins the process of permissions with the clinician. It is at that point that the patient initially immerses fully into the problem as they are living it. Encountering the problem in its entirety is the personal resonance that allows the phenomena to speak directly to the patient’s own life. Detailed inquiry and explanation by the clinician invites self-dialogue and discovery: it is the beginning of engagement of sense-scape and functional reality. This is the leverage point of skillfully engaging one’s personal fate with new insights and as the accumulated knowledge of the seen and unseen and measurable and unmeasurable grows, tacit knowledge is born. This is the range of conceptual and sensory information and images that can be brought to bear in an attempt to make sense of something; the personal knowledge that people carry in their heads that is often difficult to communicate as it often consists of habits and customs. It is knowledge that is already known and an indispensable component of personal knowledge, without which, action often leads to unintended consequences. Tacit knowledge is also described as the antonym to explicit.

As developed and understood by Michael Polanyi tacit knowledge is the combination of both the subsidiary factors and focal factors. The known, knowable, and measurable are the subsidiary. “The subsidiary factors attract immediate attention; they are essential to knowing, but of secondary importance. They stand out when we examine our experience. They are the elements of perception that enter into conscious awareness” (Moustakas, 1990) (p. 21). The focal is the unseen and invisible aspect of an experience and “is a necessary component in the achievement of unity or integration”(Moustakas, 1990) (p. 21). The Tacit is a summation and interaction of facts and experience, subsidiary and focal, which permits a view of an entire process at once. Re-engaging the narrative repeatedly re-patterns the inner landscape of intention and decision leading to a healthy and wholesome narrative. It is where the conscious patterning of healthy inquiry and narrative begins.

Conclusions

The understanding of Didactic Inquiry offers clear advantages to the promotion of health among receptive individuals and involves a minor expansion of the normal inquiry of the well-trained TCM clinician, i.e., a regular full intake and inquiry, and an awareness of the mentoring process. It provides an opportunity to bring a functional and participatory human element into the clinic as a trained peer who mentors inquiry about and understanding of mission critical organic functions and the behaviors that support them. This mentoring of homeostatic integrity is a matrix to the more specific intentions, such as medicinals or procedures. It is the substrate of wholesomeness that underlies treatment of any sort. In this the process of Didactic Inquiry contributes greatly.

Weakness in the model of Didactic Inquiry develops with both lack of valid external references and reliance on subjectivity; thus the mentoring of the educated and skillful

clinician. The seduction and tyranny of subjectivism ignores the determinist reality of biological process and competing external realities. The dominance of erroneous external principles confuses contemplation. Attenuation to the principles of functional organic process, internal and external, informs engagement, advocacy, and the development of biological and energetic integrity.

One must ask, “Does the logic of things themselves rather than persuasive arguments best inform this theory and understanding of health?” The opportunity is for the patient to discover the logic of things themselves and let the processes of things speak for themselves. It is in this simple relationship, uncomplicated by neither arguments of naïve (sensate) or scientific (observable) realism, nor the exigencies of magical thinking, that this discovery can occur.

While modern medicine and its reliance on biomedical scientific understanding of health and disease has wrought many public health benefits, it supports patient relationship that engages in little more than information gathering to diagnose and substantiate prescription or procedure. Increasing reliance on pharmaceuticals dominates the allopathic clinical model. Medical high tech is glitzy and exploitable. Does this high technology increase vagaries pushing objectivity and standards farther out of the reach of practical considerations? Possibly. Time will tell.

Polanyi questioned the neutrality of science arguing against the notion that somehow science was value free. Can one argue that the “scientific” interrogation model of health care, dependent on scientific analysis, be considered “neutral” when remedies provided most always benefit the discoverer. Again, time will tell. He argues “Real is that which is expected to reveal itself indeterminately in the future” (Polanyi, 1964) and contends, “Science advances in two ways, by discovering new facts and by the discovery of mechanisms for systems which account for the facts already known.”(Polanyi, 1964) The paradigm shift regarding biomedical medicine developed with the Flexner report of 1910 has resulted in prodigious expenditures and revenues for the biomedical industry. It has also perhaps resulted in the degradation of the generalist to the specialist who spends less than 30 minutes per year with patients, as noted earlier.

Didactic Inquiry is an awareness of the deliberate act of intending perceptual constructivism on the part of the clinician, intending to engage the patient in skillful active participation in his own endogenous life and its relationship to the exogenous flux of life that is affecting health and disease. It is the manipulation of concepts, and the mentoring of attentions to productive insights, which shape ideas and reinforce patterns of perception that result in greater understanding, enabling more cogent decisions and less self injury.

The modern medical model could be considered captive to positivist logic and therapies only warranted via the evidence based RCT model. Perhaps a reconsideration of the role of clinician and the process of medicine is to be re-evaluated. All aside, Whorf noted “That modern Chinese or Turkish scientists describe the world in the same terms as Western scientists means, of course, only that they have taken over bodily the entire Western system of rationalizations, not that they have corroborated that system from their native posts of observing” (Whorf, 1956) (p. 214).

The tension between linguistic determinism and logical positivism will continue as the creative human mind considers its dilemma of self-awareness. And while concerned with cultural and linguistic relativity, the relationship to focus and awareness of sense-scape is pregnant with opportunity for self-development. This architecture of language and concepts informs, to some extent, potential. If a motivated individual is given a map and compass and taught to navigate, they can, with mentoring, not only divine their position but also perhaps plot a course. The process of Didactic Inquiry provides context and core to this equation for some people: context meaning the surrounding world (nature) and core meaning the patient’s internal processes, inner nature and personal narrative. The language of TCM diagnostics is subjective in its perception but self evident in its manifestation.

The well-done and ongoing re-evaluation necessary for the TCM clinician is almost by definition, an opportunity for heuristic inquiry, for knowing through participation. The reliance of the TCM clinician on investigatory techniques other than lab values and x- rays necessitates intimate engagement with the patient. Moustakis reframed and expanded this notion in modern psychological terminology. This engagement provided foundational support for greater notions of the learning of tacit knowledge. The scaffolding of knowledge within the zone of proximal development is not unlike how tradesmen learn and how children develop skills. It is the art of mentoring a skillful understanding and intending health and vitality within the context of functional biological process.

The argument that this method of Didactic Inquiry is a substitute for treatment is without merit. But it is with cautious optimism that it be included in systems of health care as the one-on-one intimacy of clinical inquiry is redolent with more potential than discussion of lab values and tests alone. It seems reasonable that people would like to understand more of the dynamics of their status and that of the world so as to chart a healthy course of behavior, one bereft of unnecessary struggle.

The logic and theory of TCM have been “bracketed’ for the purposes of this paper. This empirical and philosophical medicine, while perhaps little known in the west, evidences millennia of clinical study and evaluation. It has not been within the scope of this paper to challenge nor prove its allegations, theorems nor methodologies that have developed through empirical study over the last two thousand years. The study of Chinese medicine is the study of peer review as each assertion has been reviewed endlessly in literature and in the clinic. What is taught in the classroom and practiced, as clinical medicine is the child of this process.

Do the cultural values of the Chinese influence medical goals? Probably in as much as values of longevity and health affect the lifestyle values of any mature culture. Many modern cultural values bear little if any relationship to those of mature civilizations, choosing more to justify appetites and seek tolerance and cure rather than question viability and sustainability. But perhaps this invokes questions of the Cartesian model of science wherein the soul and body are to be held separate, wherein physical manifestations of so-called spiritual integrity be separate from physical manifestations. This is hard to do in Chinese medicine, as the dichotomy is non-existent. The body-mind duality that has plagued both scientists and philosophers in the west fails to register in the

competent TCM clinician’s mind. Perhaps some day, western scientists will revel in the completeness of the plasticity of neurology and genetic expression as related to environmental forces and response. Perhaps the neo-Confucionists intuited this in their avocation of the personal cultivation of integrity as the means to health and longevity.

Western science has undergone refutation of authoritative knowledge centuries ago and thereby jumped from previously held assumptions. In doing so, some say it has left its soul behind. TCM holds to doctrines established millennia ago, yet continues to examine and test them daily. Infatuation with ”new” ideas has not discounted old theorems, as the medicine is replete with contradictory yet helpful lenses of diagnosis and clinical case discussion. This process of self-study and research needs to continue with comprehensive and competent research models, although perhaps not solely aligned with the positivist, materialistic traditions of science.

This study, basic and qualitative, is conceptual and not statistical. The theories and observations herein are not tested and yet exist in every conversation with every patient. While it is not always easy to measure what is in a person’s head it is easy to measure the results of ignorance and poor decisions. The common sense observations and understandings of organic process are not lost on the attentive individual and exist as tacit knowledge, very difficult to measure and the bane of “evidence based medicine.” The view of “freedom” of decision is bracketed and constrained by notions of viability in the clinical model and therefore not a “pure“ inquiry of human narrative and choice is not possible here. That choice has been the fad and focus of post modern and post- structuralist utterances. The clinician’s questions are deliberately leading and “pointing to” phenomena of choice, e.g., those connected with the advocacy of organic life. All these judgments of value are problematic to the quantitative study.

There was no challenge to the constructive assertion of the statement that “life is defined by organic process” although for the clinician it seems rather self-evident. Structuralism, in this context, defines human freedom and freedom of choice, defined and bracketed at the most primordial level, by biological processes. Life on planet earth and free will are ultimately governed by biological functions. Basic human freedom is best described as successful navigation within this paradigm. None of this was challenged as theory but accepted as a self-evident axiom.

The one case study offered here was selected for inclusion because the conversations were such demonstrable and noticeable additions to the medicinals and procedures that are not discussed and is employed not so much as a universal case study but an instructional one. This offered the platform for evaluation of the process and was not construed to be authoritative but merely representative. While there were many case studies available, the acknowledgment of one was sufficient reference to process within the limits of this theoretical paper.

It is (remotely) possible that this inquiry challenges the current and popular model of doctor as technician. The paradigm shift to include doctor as educator and possible mentor faces economic and cultural challenges. But perhaps it gives insight into the role of language and relationship in the clinic and the potential for participatory seeing as has been uncovered in this text. Certainly it is not new to other fields, but it is remarkably

uncommon in the conceived role of physician today. Moreover, it perhaps challenges the educational notions that provide clinicians with replete knowledge of fact and techniques but is impoverished in the communication of wholesome values and problem solving that are helpful when transmitted to patients. Perhaps also, some doctors and educators might look to consider including greater exposure to the philosophical wisdom traditions as part of medical training rather than expecting self-education, as health is more than the treatment of disease. And in doing so, discount the notion of “sham sage” for the more accurate rendition of “docere” or doctor/ teacher. Perhaps the intimate and human assay and treatments of the well-educated scholar-clinician of Chinese medicine needs to become the portal of entry to the health care system rather than the increasingly expensive specialist technician and purveyor of pharmaceuticals and high tech methodologies.

Regardless, time inevitably shapes all endeavors, however well intentioned. Sustainable models relentlessly prevail, given time and patience, as even the largest of mountains go to the sea. However without advocacy of sustainable models we impoverish our future. These are not hypotheses but axioms, discernable to the observant. The world of organic possibility is defined by process. And in the final analysis it can be said that theory cannot be used to create reality; it can only attempt to explain it (Wang, 2008). This sensible and realistic pragmatism informs the logic of TCM. It is the human dimension and it is important because we are continually influencing our internal and external environments with the choices we make and the behaviors they generate. The unspoken understanding informs the edge of becoming and thereby the cascade of what follows. And it is a hard job to interpret dreams to the muddle headed (Dan-xi, 1994): the art of life is the art of perception.

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Appendix: A Case Study

Chief Complaint:

Irregular menses (since menarche)
Pre-menstrual syndrome
Stress and back pain

History:

A 26 year old female patient visits with a medical history includes: abortion, bronchial asthma, ovarian cysts, minor surgery, vaginal infections and she is positive for human papiloma virus (HPV). Menses ranges from 20-28 day cycles with 3-7 day bleeding cycles with dark clots, significant PMS symptoms characterized by tender fibrocystic breasts, sore nipples and severe crying spells up to three days before her period. Patient tends to drink alcohol regularly (2-3 glasses of wine every other night) and admits to behavioral problems in the past such as bar fights and hair pulling while drunk as well as risky sexual behavior. There is a family history of anxiety and depression but she appears animated and slightly depressive but hopeful. She had been a basic medical science student until last year when she dropped out of school.

Her mother had been a professional working mother with high expectations of her daughter. Childhood had been somewhat chaotic with numerous divorces and parenting challenges. Her mother had been married multiple times and she evidenced distaste for all her stepfathers although freely denied any history of sexual or emotional abuse. She had become a self-described “willful wild child” who did what she wanted. Asked about her home life she admitted “to being in a relationship with a good guy who was deeply into the discipline of martial arts.” She spoke very highly of him. Patient reports her energy is low and she admits to overeating (she is overweight) and experiences bloating, especially after eating. Her bowels move slowly, urination is normal. She complains of sleep disturbances as she is often “hot and stuffy feeling” and has nightmares of monsters. Palpation revealed slight tension in the epigastric region with muscular hyper tonicity in the upper back and shoulders. Pulses were fine and slightly forceless throughout. Tongue was purple with a red tip and a thin white and dry coating. Shape was normal.

Modern medical diagnosis:

Premenstrual dysphoria (PMDD)
Premenstrual tension syndrome (PMS))
Fibrocystic breast disease,
Gastro esophageal reflux disorder (GERD)
HPV positive
Musculoskeletal pain in the upper back

The initial TCM diagnosis was:

Spleen Qi vacuity
Liver and Heart blood vacuity.
Liver Qi congestion with depressive heat.
Slight Blood Stasis
Slight Kidney and Heart yin vacuity?

Discussion

A TCM diagnosis is a working hypothesis, prone to adjustment with the progression of the case. It places one on an energetic map with a description of terrain implied in the diagnosis. The ability to affect terrain and thereby pattern is (somewhat) dependent on behaviors. These are fulcrum points where we can affect vulnerabilities and contributory issues and thereby the corrosive cascade and outcome of (disease) process. Where there is disease there is first weakness. For example, many disruptions of digestive process are associated with poor behavior as are many orthopedic issues. A careful and detailed inquiry replete with personal assessment and inventory are essential.

Energy

She woke tired and was tired all day even if she had slept well. I asked if she had ever exercised and she replied that she had in the past but was very tired all the time now and that her boyfriend had encouraged her to workout with him but that he likes to get up early and she liked to sleep. When inquiring and discussing her energy levels I first asked her how she was sleeping. Sleep has a major effect on daily energy level. She was not sleeping well. A connection was made. She had been told there were Chinese herbs for energy.

Discussion

These chief complaints point to an underlying narrative in the logic of TCM. Energy by the English dictionary definition is the strength and energy required for sustained vigor and work. Fatigue is a lack of sufficient resource in relationship to energy expenditure and stems from specific patterns of imbalance. Organisms float in a sea of nutrients and opportunity.

The TCM correlate of this energy is Qi. An essential component of life, Flaws writes “When Qi gathers there is generation of life (Qi ju ze sheng)” (Flaws, Johnston, & Rogers, Statements of Fact in Traditional Chinese Medicine, 1996). The causes of Qi vacuity are manifold as are the methods of rectification (Sionneau & Lu, 2000) (Pgs 241- 242).

Qi is said to flow like mists in the mountains. Its behavior is subject to heat and cold and damp and dryness. Emotions change the character of Qi as it descends with fear and ascends with anger. It can be stymied in its movements or dispersed and it can be replete or vacuous. All movement is dependent on Qi and all organ systems have their own particular quality of Qi. Longevity and health depend on the wholesome movement of Qi. Life itself continuing is the successful management of Qi in the face of challenges.

Qi is derived from the essence of food, the essence of air, and what is known as Jing or the essence we are born with that diminishes with age. Its availability and circulation are bound inexorably to life itself, dependent on nutrition, activity and biological time. It is a limited resource affected by nutrition, behaviors, emotions, and age. It is also essential, without it there is no life. “Once possessed of life, the human being likewise is in perpetual movement” (Dan-xi, 1994).

All post natal Qi is rooted in the Spleen, a statement of TCM fact that implies both the quality of food nourishment and the ability to transform and transport the nourishment into bodily fluids and vitality. This vitality is the substrate of all functional vitality in the body and is spent through the engagement with life. Behaviors affect gathering, circulation and expenditure of Qi and as such health, longevity, and decisions have consequences. According to the theories of Li Dong-yuan and his theory of Yin fire (Li, 1993), the process of age cascade often begins with Spleen and Stomach. The failure of adequate nutrition and the ability to transform and transport it to provide components for Blood manufacture leads to functional Blood Vacuity. The specific organs involved, Heart and Liver, lead to inhibited function of these organs. Much of typical PMS and PMDD diagnosis have Qi depression at their root.

The failure of nutrition and the transformation of this substance to the nutritive fluids (Jing ye) over time have weakened the Liver’s ability in coursing and discharging Qi resulting in depression or binding of Qi. The consequential emotional frustration of this pattern leads to self-medication with alcohol, and the stirring of heat begetting risky behavior and regrets. The weakness of Qi and blood further weakened cognitive behaviors leading to academic difficulties and failure. Lack of self-discipline and exercise further complicate issues. Not withstanding, a seemingly difficult childhood, serial stepfathers and working mother, her untutored and unrestrained willfulness added to her present state. She was making self-defeating choices and struggling with life.

Engagement

I introduced the general notion that it is possible to affect much of life by our choices and that with regard to her health there were issues that were within her control. While I was developing diagnosis and treatment plans I would discus my thinking with her if she was interested. She was.

It is from death itself that all life finds resonance. The movement towards life away from death, and its continued viability defines the essential integrity of organic processes. The clinical inquiry evokes and engages this process of return without which there is often no healing. From the recovery of illness and injury to the act of breathing and eating, all are an advocacy of life. Survival is the basic requirement of organic life. “If that is so, what kind of behavior is proper? The answer is that love life and hate death. To love fitness and to hate disease are common emotions among human beings” (Dan-xi, 1994) (p. 19).

Questions arose in conversation regarding personal narrative? Who are you? What are your dreams and where are you going. Do you hope to live long? How are you engaging this process? What do you do to stay strong and vital? Do you want to know

grandchildren? These conversations during our tenure touched on realistic goals and behaviors during discussion of her health and functions.

This resonance of relating to one’s mortality and personal inventory of behaviors affecting the rate of cascade towards death and illness in the context of the daily story affected her considerations. The inquiry began to uncover the narrative of function and the process of recovery to a state of homeostasis. Internal processes must function with vitality and be able to respond to the context of life challenges. As personal issues were brought up they were gently discussed in this context.

Choice of language was important and was deliberately used as a tool to develop reference points invoking both awareness and understanding. It began the continued patterning of inquiry around specific and significant questions relating to essential functions as described in the TCM lexicon and accessible through subjective inquiry that shapes personal narrative. It was an evaluation of the integrity of process in relation to the significant realities affecting life to reframe the facts and string together the points to create a constructive narrative of cogent facts.

For example I asked her to examine the foods she ate. We discussed the quality of what she ate and then the nutritional needs of her body for it to be healthy. I then asked her what she expected with the foods she had chosen. Then I asked her what she got.

Engaging conversation on Qi is a fruitful opportunity for discussion of many aspects of life from diet to lifestyle choices. To live a long time and not regret it, Qi must be cultivated. In some individuals it is initially a conscious practice and others a “knack’ they are born with. Self-cultivation is the deliberate and skillful acquisition, circulation and expenditure of Qi as it affects terrain that influences pathologies. Life floats in a sea of nutrients and energy in the form of stored carbon bonds and “Health is the natural state of the universe” (Larre, Schatz, & Rochat de la Valle, 1986) (pg. 8). Economize expenditures. Enhance intake. Minimize wear and tear.

I asked for details: “How does it feel to feel tired? How does it feel to feel energetic? When do you notice these feelings? What behaviors might surround them? In other words “what might you have been doing before that might be connected to this”? Did you sleep well? Have you been eating good food or were you eating poorly? Did you do any exercise and if so how did it feel? Were you drinking alcohol in the previous 24 hours?”

I wanted her to notice and feel the context of her fatigue and begin to be aware of both when she felt fatigue (and not) and what might be some surrounding issues occurring at the same time, given the TCM description of the contingencies.

After some time I then asked her to consider the above and think about ways to economize expenditure of energy. Knowing that Qi comes from food primarily, I asked her to consider her diet and whether she was eating to live or perhaps living to eat. In essence, I asked her to consider the cultivation of her energy (Qi) with the intention of having more and feeling more vital. The cultivation of Qi means to engage this process with the intention of gathering and moving Qi.

“Chinese medicine is rooted in the study of longevity. Longevity and wellbeing are rooted in the cultivation of Jing, Qi and Shen (or Essence, Vitality and Spirit) without which, there is no life. Jing can be thought of as the trust fund (financial principle) you are born with that produces interest. This interest, in combination with the essence of food and (the breath) or air, produces the daily allotment of cash flow or interest (Qi). If one of these three variables is deficient there will be less energy produced and available. The body then dips into the trust account (Jing) to make the difference. Shrinking principle produces less interest thereby quickening the process of ageing as when Jing is gone one dies.” Perhaps it was a mundane rendition of an elegant poem but it was in her language and gave her a framework with which to work.

As breath is the commander of all Qi and Qi is the commander of Blood it is important to breathe and spread the Qi. I asked her to breathe for me and watched her as she breathed shallowly into the upper chest only. She sighed often. As I repeated the description of Qi functions and responsibilities I asked her to breathe deep into her abdomen by having her place her hands on her lower abdomen below her navel and feel the incoming and outgoing. I explained again the role of breath and asked her to be aware of sighing, a sign that she was not breathing deeply. With this I gave her an assignment to lie quietly in both evening and early morning (with bedtime) to practice this for five minutes then slowly expanding the practice to once or twice per day, concentrating on how it felt. It was important to do it every day.

I encouraged her to ponder the following questions, which we discussed regularly with regards to the aforementioned statements of fact.

Where do you get your energy? As all post natal Qi is rooted in the Spleen, consider the source and discipline of eating in order to live well.
How do you circulate your energy? As breath is the commander of Qi and Qi is the commander of Blood, how do you propose to circulate your Qi? You have pain in your upper back and shoulders. Where there is free flow there is no pain, where there is pain there is no free flow. (Tong zi bu tong, bu tong zi tong) How do you feel when you exercise? Maybe try a small yet regular exercise program initially and see how it feels. Do you have any ideas? How does this work for you?
How do you spend your energy? Your personal energy is a limited commodity. Aside from your spending it on the basic physiological processes, how do you spend your time and energy? Do you spend it gathering more energy or are your endeavors free from such considerations? What are the current patterns of behavior that may affect fatigue; make you more tired or less tired? What are the possible outcomes of current choices regarding your energy gathering and expenditures? How are these choices and decisions working for you?
Do you have any ideas or further comments?

Low energy means low defenses and poor thinking. Low energy also stagnates easily causing emotional frustrations. Low energy may draw from mission critical processes.

What is mission critical? She suggested personal protection and food. I asked her if she felt she was in shape to either protect herself or run any distance to escape should the

need occur. She said no and I asked how she felt about it. “Not good,” she said. I asked her to think about the consequences of her status, how she felt it and what she might do for a plan to change it. I also suggested that she think about these consequences as motivators, like thinking about her death. Months after this initial conversation this still resonated with her. There was something she could do to stay free. How would she feel if she let that opportunity slip by?

I asked her about her dreams. Did they include mastery of the basics, safety, food and shelter? She had limited energy. I suggested she spend it first on these if she intended to remain free.

Energy (Qi) is seen as one of the three heavenly treasures it is thereby something to be treasured. All postnatal Qi is rooted in the spleen, thereby food and the process of eating is important, as is the deliberate and economical expenditure of Qi in fulfilling this primary root of life.

I shared a personal story with her. “I was once deep in the wilderness on an aboriginal life skills training course with a well-renowned teacher. There had been almost no food for four days. I felt exhausted, light headed, and leaden all at the same time. While wandering along a stream I ran across a small patch of wild strawberries in the forest clearing. I lay down and grazed about one half cup of them. Within ten minutes I felt a surging of energy flowing through my muscles. When I stood up I noticed another clearing about five hundred yards across the steep canyon. I started across the mountain and my energy was good for most of the way but just as I reached the field it was as though someone pulled the plug and the sudden burst disappeared. Again I grazed and again the surge. It was the first realization of food equals energy. I had a new and limited charge to find more food before my body once again slipped into a catabolic state. This is the primordial need of energy expenditure, to find more good food. But weather threatened and I returned upstream a bit to a natural bench along the creek to build a shelter and get a fire started for the night as I had found bear tracks in the mud along the creek.”

The basis of human survival is the acquisition of food (Qi), its proper and economical distribution to provide the basic necessities. “Is this done well?” I asked her. If she were unable to take care of these things who would and what would she be giving up for them to do it?

Emotions

She describes a history of anxiety and depression and notes there is a family history of the same.

Her emotions were across the board. Passionate, she was excited and hopeful then depressed about her failure to finish school. While neither were extreme, it seemed clear that she had little emotional center. She was busy yet accomplishing little. Her job as nanny renewed her interest in having children but her boyfriend wanted none for the time, preferring to wait until she finished school. She felt her mother was being judgmental about her lifestyle yet she had no plans other than the nanny job. She had

been going out drinking with friends in the evenings (every other) and having two or three cocktails or glasses of wine. Once, recently, while inebriated, she engaged in a sexual relationship outside her primary one. For this she was feeling guilt and self- loathing at her lack of self -control. The decision to see me came from a subsequent bar fight with the same male and his girlfriend where she lost some hair in a scuffle.

Discussion

While she was clearly unhappy with her situation, much of it was of her own making. Emotions affect the body and are known as the seven affects in TCM for a reason. Childhood had been somewhat chaotic with divorce and parenting challenges. She had become a self-described willful wild child who did what she wanted. Her open expression of anger and the subsequent fight produced deep regret, as did her infidelity.

Wiseman (Wiseman & Feng, 1998) defines emotion (情感 qing zhi) as “affect or mind.” (p. 172) and mind (zhi/ spirit mind) as “1. Will, determination. 2. Capacity to think, feel, and respond. 3. Affect, emotion. [...] 4. Memory; will.”

The relationship between mind and the capacity to think and respond clearly to life’s challenges and plan accordingly is intimately connected to the quality of emotional state. Will and determination are also associated with the concept of mind as the capacity to feel and think, respond. While the English definition of emotion is “a natural instinctive state of mind deriving from one's circumstances, mood, or relationships with others in other words a feeling”, it develops deeper significance through the eyes of a TCM doctor. Emotions, though an important part of the human experience, are not only passive but active in that they affect the circulation of Qi and thus, over time, affect organ function and health. The model is clearly stated in the literary and clinical tradition of TCM. Dan- xi wrote:

“The sages stipulated (as norms) justice and uprightness, compassion and honesty, and advocated stillness.” (Pg 112) and “that happiness or misfortune, regret and shame are all produced from stirring (or movement).” “ It follows that disease in human beings is also a product of stirring, and, in extreme, disease ends in death” (Dan-xi, 1994) (p. 124-125).

Engagement

I began asking her if she had any control over her emotions or whether she felt as though she was just a victim of circumstance. She recognized that she had some control but felt as though they were spinning out of her control. After discussing her current state I asked her to envision where she would be with such behavior in ten years. Then I asked her what she had planned to be doing in ten years. The contrast was remarkable and she responded emotionally.

Very animated, she had apparently not considered the value of stillness. I noted that movement is easy but stillness is difficult (Dan-xi, 1994)(p.125). I asked her if she was happy with the state of her life and her emotional state to which she answered “definitely not.” Asking if she was perhaps interested in living her life a bit more skillfully and less

chaotically, I gently introduced the notion of self-cultivation and suggested that it is the deliberate and ongoing relationship with an organic process.

It was clear to her that emotions were a partial cause of her problems in life. I noted that there were perhaps good reasons to work at being calm and thoughtful; that there were values in this behavior. That perhaps she could be more effective in dealing with life and that it might not seem so chaotic. I asked her if she thought this might be helpful in relationships and studies. She found the idea appealing.

I initially encouraged her to spend some quiet personal time where she would first allow herself to feel calm. When she felt calm and set with it for a bit I asked her to think of something that made her upset and I asked her to note how that felt in her body. Where did she feel it and what did it feel like. This was not to be at the same time as the breathing exercises initially so as not to confuse the two but after time the practice could become one of self awareness, a referenced rooting point for stabilizing emotions and awareness in the feeling of breathing.

Over the course of treatments I encouraged her to be attentive to recognizing her emotions for what they were and the effect they had on her perceptions and decisions as well as her physical feelings. Did she come to clear decisions when she was upset and if not, how did she feel about it? Was this what she wanted to do? If not, what was she going to do about it? We briefly discussed various issues as they came up in the context of her larger plan to cultivate the strength, clarity and balance to live life more in control and with fewer vulnerabilities.

People do all sorts of things of which they are not aware. I encouraged her to be attentive to these emotions to become aware and conscious of what she was doing and what she was intending with her thoughts unconsciously. In short, I encouraged her to explore her inner narrative and play it against the new one she was developing. The motivation for this was that her life was fairly chaotic and added to her PMDD and she did not like the physical nor emotional discomfort of her condition. I used that discomfort as a reference point or mirror of sorts to contrast her newly developing values and behaviors. “If you are upset and make a decision to eat cake instead of lunch, how do you feel? Does the cake feel like nourishing food while you are eating it? Do you feel you have more energy or less energy afterwards? How do you feel about yourself after you do that? Is this something you want to continue? What do you plan to do about it? Anything?”

The emotional state and the body continually rearrange themselves in response to environmental challenges. The mind keeps track of this (often unconsciously). Learning what works and doesn’t work develops skillful behavioral responses to these challenges. Initially taught by parents and social constructs (values), the notions of emotional homeostasis become internalized. The framework becomes personal and (hopefully) functional. As pleasure and pain are experienced with behaviors, neurological circuitry is wired in the process. “As we fire so we wire” is what is known from the science of neuroplasticity. In essence, we can develop hardwired appetites for pleasurable behaviors. This has lead to affection for and indeed indentifying with behaviors distant to viability and survival. In the context of natural evolution attraction to the pleasure of certain behaviors has been a boon. But in her case, little mentoring and delayed feedback

(the eating and drinking affects on health would show up much later in life), her behaviors and habits continued. People get weaker and this invites misfortunes. The somatic and immediate unpleasantries of these behaviors became a learning tool, as were the value statements of TCM reflecting life vitality.

In short, I encouraged her in a contemplative activity, the regular process of cultivating stillness following her exercise program. This was to be an emotional and mental rooting process that would allow for self-evaluation and reflection. Li Dong-yuan notes

“Anger, indignation, sorrow, worry, fear, and fright can all cause detriment to the original Qi...therefore, the seven passions are not quiet. The heart sovereign is not calm, transformation may give rise to, and fire is the foe to the seven spirits [i.e. the ethereal soul, corporeal soul, essence, spirit, reflection, intelligence, and mind]” (Flaws & Lake M.D., Chinese Medical Psychiatry, 2001) (Pg 7).

TCM speaks of this emotional frustration and lability as associated with depressive heat. “If, unperturbed by not knowing what to blame, one continues to willfully violate the (relevant) prohibitions, the old pattern already inflicted will accumulate (more and more) with each passing day” (Dan-xi, 1994).

Unresolved emotional issues, unfulfilled desires, unmet expectations, and generally un- metabolized life experiences overload the ability of the (Liver energy). This results in congestion. Enduring congestion generates heat as the body seeks to manage the increased stress. Yuan Qi (source Qi) is enhanced to disperse upwards and outwards. In her case this transference was into the Shao Yang channels of the upper back and neck as well as into the pelvic region, resulting in stiff shoulders and menstrual irregularity respectively. In short, her emotions (and subsequent decisions) were affecting Qi circulation, which inturn were causing the very symptoms she was complaining about. Faulty considerations for relaxing by drinking alcohol and sleeping late were adding to rather than subtracting from her problems.

I suggested she stay away from the bars and join a yoga class or martial arts class and develop community there. Dan-xi said “See not that which is desired, and the heart will be kept from being upset.” (Dan-xi, 1994) I gave her this as a homework assignment and asked her to do it two times per week for a month then come back and tell me how she felt.

Food

She admits to overeating comfort foods and is overweight. She also admitted to going out and drinking alcohol on an average of every other night. Reflux was not uncommon with bloating especially after eating and her bowels move slowly

“The Nei Jing repeatedly instructs to enrich the source of transformation” (Dan-xi, 1994). The Statement of fact regarding Stomach in TCM is that it receives, ripens, and rots food and descends it. The substance then passes to the Small Intestine where the pure is separated from the impure.

In conversation with her I strove to explain the underlying energetic process and engage her in deliberation of her actions. The examination of her appetites led her to the conclusion that she was eating, in part, for comfort. She found sweets and carbohydrate snacks relaxing. Alcohol did the same thing but with it came the added benefit of forgetting unfulfilled goals, which, perversely, were in part, a result of her drinking. Alcohol made her lazy, and self described “sloppy” and with a poor diet, fat. Zhu Dan-xi refers to those who drink as the (muddle-headed) ones, unable to think clearly and bound to arouse passions and invite misfortune (Dan-xi, 1994). She had dreams of becoming a professional but has lost interest in the studying process as she had trouble focusing. Besides, it was hard to stay awake in class. As she understood the relationship between eating and nourishment of the mind she began eating both more regularly and with more attention to nourishing foods. This, however, is a slow process. Her mother had been a working professional woman with high expectations of her daughter but the family life appeared chaotic with multiple marriages. My suspicions were that her behavioral education consisted mostly of explicit commands rather than mentoring. Although this is speculative, the patient seemed to have some knowledge of good food but little experience.

With developed verbal skills, she was a good communicator but prone to sharp comments, thus the fight and untimely hair loss. I noted, “The mouth is capable of causing disease and also of ruining one’s virtue” – attributed to Mencius (Dan-xi, 1994). She laughed and said it was also helping her get a new job as a waitress. I encouraged her to consider the long-term consequences of poor diet as her story. and asked how she felt about being fat (she had described herself as overweight). We discussed the specifics in detail. She began to get religion around what she put in her mouth. “... there are no end of cases where the body is damaged for the sake of the mouth.” (Dan-xi, 1994)

Summary

Much of the first couple of inquiries were spent listening to her story and taking notes before treatment, steering her to repetition of not only the chief complaints and larger personal issues but briefly how she felt about her life and where she thought it was headed. I introduced the notion that it is possible to affect vulnerabilities and the course of life through skillful and disciplined attentions to significant issues. In short, I wanted her to step into her narrative of complaints where I offered commentary and more questions to flesh out the details. The story became her story of choices and consequences. But the continual steering of conversation was back to the significant issues of the standard TCM interview. Each question regarding energy, emotions, appetites, digestion, etc. were continually framed in the context of her own narrative and then referenced in the context of the narrative of what might be considered statements of fact in TCM. This reflective process began to, over time, affect her language usage to the point that when I asked her how she was, she began to go down the checklist of questions I would ask her in the normal course of inquiry, without prompting. These points of reference were becoming internal points of significant reference as opposed to mere external constructs. Over time this back and forth dialogue between the external references and the internal sense-scape, that was developing around the reference to the quality of significant organic process, resulted in her developing the rudiments of a

personal plan of action based on where she wanted to be in five years. The plan of action was grounded in very simple behaviors and disciplines based in the nourishment of her own life; rules of thumb that linked decisions to favorable outcomes (given the realities of organic processes):

Get up early (it will eventually make you go to bed early)
Eat breakfast (start the day nourishing yourself)
Exercise every other day. Exercise moves Qi and Blood and calms the mind.
Cultivate stillness and contemplate impacts of one’s behaviors and choices in the
greater context of how the big picture works to discover the logic of things themselves.

Discipline yourself to do anything regularly and you will slowly grow internal strength. The trick is to do it regularly. I encouraged her to consider a plan to connect her dreams to the daily events. That is to say “eat breakfast if you want a college degree.”