TCM: Managing Our Expectations of Tongue and Pulse
Stories: they help us remember. However, they can be of some detriment due to their tendency towards exaggeration. I’m sure most of us have heard the saying, “Never meet your heroes,” because one finds themselves in the company of mere mortals who have the same trappings and failings as oneself. This is true of taking stories, legends and fables to an unrealistic realm.
For most of us, we went to Chinese medicine college after experiencing the strength of what acupuncture or herbs could do - and then decided to learn how to help others. When we began our treatments we experienced the practitioner checking our tongue and feeling our wrist pulse. Perhaps we even had a practitioner compare wrist to neck pulse. Of course, these types of diagnostics were very intriguing.
Fast forward to my first year of college: I heard stories of a visiting doctor of Chinese medicine the previous year. This gentleman, as the story was told, took many pulses during his visit. Second- and third-year students recounted how he would tell them they had just had intercourse, or they just got over a cold, or that they just ate McDonald’s. It seemed so much information could be gleaned from the pulse. Yet, why I wondered, were we taught only the pulse images verbally and left to our own devices to figure out pulse diagnosis all alone? I came to find out, after many years in practice, many colleges and universities did it just the same…
Reading tongues can be a lot of fun. Prickles here, cracks over there, a thick or missing coating - there’s so much information to be gleaned from the tongue. Tongue diagnostics seemed easier to learn. My instructors saw a red tongue body and I saw red. My instructors saw a centreline crack and I saw a crack. It seemed easy enough. There were no poems or ‘images’ of how something felt. The tongue was objective where the pulse was subjective.
Everything about the tongue diagnosis was easier than pulse - until it came to picking a point prescription. During observation hours I watched student clinicians just about ignore the tongue. Fully licensed acupuncturists would often not even ask to see a patient’s tongue. I didn’t understand…
…I thought: if I was supposed to be able to tell what someone had for breakfast by feeling a patient’s pulse, and then look at their tongue and see plain as day they have Heart-Fire, these diagnostics must be of huge importance. The stories, legends and fables told me so!
May 8th, 2019 marked me going into my 12th year practice. I’ve worked hard to hone my diagnostic skills and I have learned a lot from my patients. Calling what we do ‘practicing medicine’ is an accurate synopsis. I’ve been asking my patients the same questions for 11 years. Taking a term from Malcolm Gladwell’s book Blink, I can thin-slice my patients and come up with acupoint prescriptions extremely fast. And all this is done during the interview phase long before I ask to see a tongue or check a pulse.
When we ask our patients about their bowels, we don’t take that information to have more weight compared to, say, sleep. Diagnosing sleep isn’t more important than diagnosing menstruation. We view each question as giving the same amount of information as the next. So, then, why do we have unrealistic expectations of tongue and pulse? Are their diagnostic values truly greater than questioning our patients?
I truly believe we should lower our expectations of what tongue and pulse diagnosis can provide, and at the same time I do not agree with not checking the tongue and pulse as they are part of each patient’s visit with me.
I think it’s important to ask the same questions over and over to our patients. Each time we see them they have a chance to answer differently and this always gives us more clues as how to better treat them. The same goes for tongue and pulse - checking each visit allows us to watch them change over a course of treatment. Just as we get to know, say, a patient’s pain, we get to know their pulse - often finding an irregular heartbeat after a few visits that can be reported to their MD.
However, my patient’s chief concerns trump anything the tongue and pulse shows. Oftentimes I post pictures of tongues to my TCMgraduateTV Instagram account. I spend a lot of time diagnosing the picture and offering Heavy Hitting acupoints to help treat the patient’s Root condition. It’s a lot of fun and I absolutely love the interactions and debates with people. From time to time I will get a question such as, “You provided a lot of acupoint options. Which points did you end up using?” To which I find myself replying, “Only HT7. The patient was coming for knee pain so a lot of my acupoints were directed there.”
There is no question that if a patient was coming for an internal condition instead of a musculoskeletal one I would be using more Root acupoints, but pain is the top reason most patients seek out an acupuncturist so I tend to treat a lot of pain. I am grateful to help so many pain patients. As I develop a relationship with them they learn about all the other amazing things I can do and through their referrals I receive other patients with more internal Chinese organ concerns.
When interviewing a patient, they often tell us symptoms that don’t make sense - or rather - they don’t fit with the language we use. One of my solutions to this is to chart but ignore it for the time being. The Strength of TCM is in its ability to create a pattern diagnosis. If there is one symptom that is a Branch on its own I monitor it but know that there are many other branches that will provide me with a Chinese medicine diagnosis.
The same can be said for tongue and pulse. Many times in my career I have had conflicting information between what my patient describes and what their tongue and/or pulse shows. So I chart it and ignore it. I go with what my patient is describing because their reality and how they feel inside their body is the most important diagnostic to me. More important than tongue and pulse - combined!
Lastly, learning pulse is hard and often a practitioner feels alone in their endeavour. When a student or a seasoned acupuncturist asks for help or mentorship in this field they are left feeling empty. We find out our supervisors, teachers and mentors don’t know what the heck they are doing either. This can make us feel jaded about continuing our studies.
I offer two suggestions to help teach pulse diagnosis to yourself:
Track down a copy of Bob Flaws’ The Secret of Pulse Diagnosis. Memorize the pulse poems.
Watch my video on how I reverse engineer the process of learning pulse diagnosis.
I truly hope this post has been of some help. Don’t beat yourself up for not having the tongue and pulse diagnostic skills that are the stuff of legend. They don’t exist. Lower your expectations of what tongue and pulse can give you in the clinic - and raise your expectations of what diagnosing through asking can achieve. It’s taken me 11 years to be able to feel over half of the 28 pulse poems and most of the time in the clinic I feel mostly between 5-8. Just like heavy hitting acupoints, there are heavy hitting pulses. Wiry, slippery, thready, choppy, hidden, leathery, floating, rapid, slow, regularly irregular…