ALTERNATIVE THERAPIES IN HEALTH AND MEDICINE ___A PEER-REVIEWED JOURNAL * MARCH 1999 + VOL. 5, NO. 2 HYPNOSIS TO ACCELERATE HEALING » CONTROL IN MIND-BODY MEDICINE » PATIENT-PHYSIL N COMMUNICATION * TIBETAN MEDICAL DIAGNOSIS » TOLERANCE » PRAYER CIRCLE » NCCAM » SYMPOSIUM ABSTRACTS * CONVERSATIONS/MICHAEL MURRAYTOY Eliot Tokar practices traditional Asian medicine in New ‘York, NY. From 1983 to 1986 he studied Tibetan medicine as, a student of Dr Yeshi Donden. From 1986 to the present he hhas been a student of Dr Trogawa Rinpoche, and from 1990 to the present he has been a student of Dr Shakya Dorje, Fle is one of the only North Americans fo have received such training, Trained in Chinese and Japanese tradition] medi- cine as well, Mr Tokar has lectured extensively on Tibetan medicine and natura! healthcare alternatives. He advises the American Medical Students Association's National Project on. Complementary and Alternative Medicine. Tomake use ofan oncient traditional neal stem, we rust fst comprehend the singular concepis and language that system uses io understand and describe heath and ilness. The diagracie procedure is ‘the method by which a person's medical condition is inkepreted into the conceptual framework and language of medial sclence. Ths aril pro- vides @ description of traditional Tibetan medical diagnosis and explains how a Tibetan physician perceives ane anabzes a presenting ness Ie diseases the spiritual, psychological, and piyscal aspects of the Tibetan medical approach to diagnasis. Addressing hese suet can help 1s to understand what to walque about this system of eternative med cine and how it can inform other models of medtcal practic. (Alem ‘Ther Health Med, 19995 2)50-58) then most patients seek a doctor for a med- fcal diagnosis, they generally assume that the process will clearly and directly reveal the truth about their condition. Their assumption is thet the diagnostic procedure ‘ill reveal cher ness in much the samme way that cutting open an apple bears its core. in most cases, however, nothing could be far- ther from the truth. In exartining the nature of diagnostic procedures, it is worthwhile to recall the Indian tale of the blind men who apd pus ne Yen Comvtain, 1 Canbia, kVg CA EK pene, (G0 8991120 O19 $46 309 (a1 51 fo, AO) SBOE eal eRe SEEING TO THE DISTANT MOUNTAIN: DIAGNOSIS IN TIBETAN MEDICINE Eliot Tokar Origioally presented to the Roundtable on Traditional Medicine, olumnbia Presbyterian Hospital; New York, NY; April 28,1997, Modified for Alternative Therapies in Health aad Medicine. ‘encountered an elephant. In this story each man, feeling only ‘one part of the elephant, draws a completely different and. erroneous conclusion about what he holds in his hands. Nowe ‘of them perceives that he is touching an elephant. Instead, Judging from limited experience, each decides that the part he is experiencing must equal the whole: the leg is thought to be a tree tramk, the tal a rope, the trunk a snake, and so on. Jn medical diagnosis we healthcare practitioners begin with ‘our own biases, which are based on our personal, cultural, and. professional worldview, thus forming the basis either for our blindness or our insight. We obtain a limited set of information that is derived from tests and/or other techniques defined by ‘our tradition’s medical science, Through this analysis, which is based on our understanding, experience, and awareness, we atternpt to comprehend the truth ofthe condition. ‘we are to succeed we must do better than the blind men ‘of the tale. By experiencing the trunk, leg, or tusk, we roust be able finally to perceive the whole. We must ultimately have the insight and skill to see the entire elephant. However, because of the blindness inherent in the prejudices and limitations of any worldview, we will inevitably see a slightly or even @ radically different elephant. LEARNING TO SEE In the teachings of Tibetan medicine there is a metaptor that refers to the stages of development of the diggnosticon, At the first-level a student of medicine is likened to a person stand ing on a mountain top who is unable to perceive what is on the top of the opposite peak. At the next level the student can see that something is there. Ata higher level the student can per ceive that someone is standing on the opposite peak but he or she stil lacks the ability to perceive anything about that person, ‘At many succeeding levels, mort and more can be perésived about this person until, ultimately, at the most advanced degree of ability, the student recognizes precisely who is there. ‘This metaphor describes the evolation of perceptive abil ties in earning Tibetan medical diagnosis. (ts meaning can also apply to the gradual process that practitioners of different med- ‘eal systems mast undergo to truly perceive what a doctor from 50 ALTERNATIVE THERAPIES, MARCH 1999, VOL. 5, NO. 2 Secng he Dial Moun Diagn inTiben Meine‘another seientifie worldview sees, Performing a medical diagno- sis requires an understanding of the technique and language of the system within which one is operating. The foundation of diagnostic still, however, is the development of a capacity of awareness that leads to dear and precise perception. The following article will explain the basic tools and Jan- ‘guage of Tibetan diagnosis and begin to clear the mist that stands between the peak of Tibetan medicine and that of other ‘medical traditions. To begin establishing a complementary approach to medicine, there must be 2 common language creat- ed through which traditional and allopathic doctors can effec tively communicate about thelr disciplines. Medical traditions ‘ate not the sum total oftheir diagnostic or treatment techniques; instead, they are the result of the scientific, cultural, and spiritu- al knowledge that gave rise to those therapeutic applications. To establish a common language of communication, we must begin by seeing clearly. ‘This point is demonstrated in the book Mortal Lessons by the surgean and Yale professor Richacd Selzer, MD Tn tis book Dr Selzer recounts a diagnostic session pecformed by my first teacher, Dr Yeshi Donden. The session was part ofa demonstra tion conducted at an American hospital Dx Donden was shown 1 patient about wham he was told nothing, Before an audience of skeptical Western physicians, Dr Donden performed the ‘Tibetan pulse diagnosis and urinalysis. To the amazement of his audience he was able to accurately diagnose that the patient bad 2 chronic beart problem. He diagnosed an imbalance in the basic citculatory principle of the body as it relates to blood and heart function, This disorder had progressed to a stage in which it affected the patiea’s preexisting heart ixsegularity, which had developed during a specific stage of embryological development. Dr Selzer resounted the agnosis in this manner: IDs Donden] speaks of winds coursing through the body of the woman, currents that break against bares, eddy- ing. These vortices are in her biood, he says. The lst spend- ings of an imperfect heort. Between the chambers of her heart, long tong before she was born, a wiod had come and blown open a deep gate that must never be opened. ‘Through it charge the full waters of her river, as the moun- tain stream cascades in the springtime, battering knocking loose the land and flooding her breath. ‘The allopathic diagnosis had been “congenital beart dis- ease," an “interventricular septal defect, with cesultent heart fail ure.” To Dr Selzer, who was used to the worldview, technique, and jargon of his profession, the Tibetan diagnosis seemed remarkably poetic. Dr Selzer described this diagnosis a a largely divine mystical experience accessible to prlests but not to mere doctors.’ Interest, fascination, and perhaps even respect were engendered, but little understanding between the doctors seemed to develop. In fac, what Dr Donden was dolng was not ‘magic. He was doing what was expected of a properly trained ‘Tibetan physicin, albeitat its highest level. ‘LIKE A RICH MAN WITH ONE CENLD In describing bow he worked as a physician, my teacher, Dr ‘Trogawa Rinpoche,’ remarked: “My external activity isthe prac- tice of medicine, and in my inner thoughts 1 meditate on the Medicine Buddha.” This comment does not simply tell us that Dx Trogawa is a religious or pious man. Properly understood, this remark displays the first step in the process and practice of Tibetan medical diagnosis. It isan ongoing practice toward spisi- tual development and its resultant awareness and intention, ‘toward which the physician continually strives. Given the differ- ing levels of practice and development that exist among Tibetan doctors, there [s no quantitatively prescribed standard for this aspect of medical practice. till, the primary classic principle of ‘Tibetan medical practices that the bedrock of one's approach to diagnosis lies within the doctot’s spiritual practice, In describing the Tibetan approach to diagnosis itis vital to understand haw the properly trained Tibetan doctor sees the world, Afterall, it is always within a doctor's subjective under- standing ofthe nature ofthe phenomenal world thatthe reltive- ly objective work of obtaining a diagnosis oceurs. How, then, do Buddhist teachings determine the basis for making a clear diag- nosis ofiliness? Because the historical Buddha deserved his role and teach- ing in a fundsmentally medical fashion, this eonnection is very direct. In fact, because the Buddha's teachings were me cure suffering, he was known as the “Sugreme Physician.”* The Buddha is therefore a direct inspiration for Tibetan doctors, who attempt to emulate this model ofa spirtualy realized being who makes a conscious choice to cure others. ‘To appreciate how a particular medical system approaches diagnosis, one must discover how a doctor trained in that system perceives the patient. It i Important to comprehend the doctor's cooscious intention. Buddhist teachings delineate Tibetan doc- tors’ image of themselves and theic patients as wel as the doctor- patient relationship. Buddhism’s cencal tezchings and practices place great emphasis on (1) understanding and discovering the nature of one's mind, and thereby transcending ego: (2) develop- Ing a practice of compassion toward all other conscious beings: and @) developing a sense of equanimity. Therefore, for the doc- tor of Tibetan medicine there (sno psychological or professional dilemma in directly identifying with his oc her patient—as there canbe, orinstance, in Western medicine. In.a sense, the Tibetan physician intentionally sees to identify with the patient. I is, important for us as physicians co intimately understand the basic natare of suffering—both the patients and the dactor's— aswell as to understand that our relationship to the patient has both a professional and spkitual significance. ‘Though spiztual practice the Tibetan doctor is trained to emolate a highly spiitually evolved person. A direct connection develops between the doctor's perception of the patient and a Bodhisattva’s perception of all beings. The term “Bodhisattva” literally means “hero of enlightenment.” Bodhisatovas are spit tual trainees who strive to generate an altruistic mind oflove and compassion.‘ They are basically Buddhas in the making who Soave Dist Noone Dag in Tibetan ene ALTERNATIVE THERAPIES, MARCH 1999, VOL. S,NO.2 51hhave dedicated their pursuit of spiticual avareness to the single goal of bringing about the welfare af all. ‘We can get a glimpse of the professional ethic Dr ‘Trogawa endeavors to practice in an instruction from the Buddhist sage Vimalakirti: 1am il because all sentient beings are i che illness ofall, sentient beings were to come to an end, then nty illness would be ended. Why is this so? Because when the Bodhisattva enters into the realm ofbirth and death forthe sake of beings, he becomes subject to the laws of this realm and thereupon ‘becomes il. fal sentient beings were to be cured oftheir ds- cases, then the Bodhisattva would never be ill again. ‘tis like the rich man who only has one child, When his child beconnes i, his parents become il Ifthe son is cured of disease, s0 also are the parents. It is the same for the Bodhisattva: he loves all beings as if each of them were his child. When afl beings are cured, then the Bodhisattva will be cured... Before seeing their first patient, Tibetan doctors practice an archetypal diagnosis that becomes a basis far all the diagnoses they will perform throughout life. This diagnosis is visualized in a ‘meditation practice used by traditionally trained Tibetan doctors. In this meditation physicians visualize the “Buddha of Medicine,” seeing all beings before him, with their particular su(fering and all ofthe innumerable diseases they may have, The Medicine Budldha feels anguish for them and wishes them free- dom from suffering, Through the power of his realized mind, this Medicine Buddha diagnoses the illnesses as symptomatic of fundamental spiritual disharmony caused by ignorance, This ‘Ignorance is a lack of understanding of the basic nature of realt- ty, as understood from the Buddhist perspective. ‘The resultant confusion leads to activites of our body and. mind that directly or indirectly lead to suffering and islness. Given this diagnosis, the Medicine Buddha understands the temporary. iUusory nature of illness, Pushing through his sense of anguish, be delves deeper into this and sees that within every atom of every being who appears as suffering, there exists a Medicine Buddha. Be experiences inner joy in the knowledge that despite suffering, there is the potential for boundless happ}- ness. Having completed his diagnosis, the Medicine Buddha pro jects a purifying energy from himself to those before him that reveals the inherently healthy state ‘At this point in the meditation, practitioners merge their own selves with the being of the Medicine Buddha and become indistinguishable from him. They then proceed to a state of ‘meditative emptiness derived from the understanding of the Buddhist teachings, In relation to ehis emptiness, all the forms and concepts we occupy in life~including illness—are wader stood as illusory, dream-like, and therefore highly changeable. Thos it follows chat iliness is roade worse or better by changes in the mental perception we give it, The Medicine Buddhe's profound diagnostic skills are derived from wisdom based on deep awareness and perception. ‘These qualities, along with his resultant capacity to heal, makes the Medicine Buddha the role model forthe physician of Tibetan. medicine. By visualizing themselves a5 Medicine Buddha, doc- tors of Tibetan medicine pursue an aspiration to develop the same capacity for compassion, awareness, and sidlifulness. This process is the root from which diagnostic skill develops. It is established even before the frst patient walks in the door. ‘THE ROOT, THE TRER, THE BRANCHES, THE LEAVES, ‘THE FRUIT All medical systems grow from 3 roots: (1) faith and beliof (2) experience and perception, and (3) objectivity and analysis ‘Westem medicine generally claims to need only the third root, ‘excluding the significance of faith and belief and imagining that experience and perception are superseded by an assumption of scientific objectivity and analysis. Fortunately, as the grassroots alternative medicine movernent becomes a prominent force, ‘Western medicine is beginning to grant some significance to ‘these 2 other roots. Examples of this are Larry Dossey/s? and Herbert Benson's work on the value of futh and belief in treat- _ment, and Oliver Sacks assertion that the subjective experience ‘of the patients useful tool in diagnosis. Practitioners of Tibetan medicine have always depended on all $ roots to properly per- ceive and analyze an liness and its cause in the diagnostic setting. By synthesizing knowledge from various medical systems, ‘Tibetans created a systernatic approach to medical science draw ing from thousands of years of accumulated empirical know!- edge and intuition about the nature of health and illness. Centuries ago, before Buddhism entered Tibet, Tibetans, ike all ancient people, had a significant degree of medical knowledge. According to traditional sources, in che beginning ofthe 4th cen- tury many new ideas regarding medicine began to entec the country. At frst, influences came from India in the form of what Ss now called Ayurvedie medicine, as well as more spiritually and psychologically based systems from Buddhist and other sources. ‘Around the 7th to 8th centusies the Tibetan government began sponsoring conferences at which doctors skilled in the ‘medical systems of China, Persia, India, and Greece presented ‘and debated their ideas regarding health and the treatment ofill- ness. Those with superior abilities in the diagnosis, treatment, and understanding ofiliness were invited to stay and contribute to the country’s medical Inowledge base. In the 11th century ‘this knowledge was codified into a unique system." ‘To properly perform Tibetan medical diagnosis, a doctor ‘must have an understanding of che theories of Tlbetan medicine and thetr unique description of the body—its creation, principal energies, fonctions, and processes—as wel a8 an understanding cof health and the etiology of ness. As with Western medicine, he quantitative aspect of knowledge in medicine most be mde stood and internalized so it can be readily drawn upon in the diagnostic session. Through instruction from a master and ‘through their own practice, Tibetan doctors in training also gain experience with the qualitative understanding and analysis that 52 ALTERNATIVE THERAPIES. MARCH 1999. VOL. 5, NO. 2 ‘isi ini inlaid ahah Dada ia heli:[ essential in Tibetan medicine, This qualitative dimension clearly differentiates Tibetan medicine from the mechanistic view of Western medicine. Tibetan medicine views the human ‘body as an ecological system, 2 microcosm diectly related to the macrocosm of the natural world. Al of the material that makes up our univers is based on the qualities of 5 basic elements, which are described in the ancient physics and depicted in Tibetan medicine. Like all tradi tonal people, Tibetans lived in direct contact with the natural environment. «They understood through experience and study that natural environmental forces directly correlated with and. influenced the functioning of the hurnan organisms Tibetans defined the qualies ofthe basic forces exsting in nature in the theory of the 5 elements. These forces ace named for their most identifiable manifestations: Earth, Water, Fire, Wind. and Space. ‘The characterises (such asa substance’ taste) and therefore the nature of ail matter resatt from the qualities of these elements individually orin combination. Earth has qualities of flanness and stability and therefore provides the basis of physical existence and development. ‘Water ereates moisture, giving rise to all fluids. Wind creates ‘movement and so enables all aspects of eireulation and move- ment. Fire creates transformation, metabolic functions, and activity. Space provides the potential for existence to be creat- ‘ed In the first place. Combinations of these qualities make up the physical aspect of our hodies as well as the body's distinct physiological energies.‘ 4s with aay medical system, understanding the vatious functions of the body is important in Tibetan medicine. However, the underlying physiological princigles that ereate and maintain ‘hase functions are of primary importance. Tibetan medicine defines 3 main systems that control all the body’s functions. ‘These 3 systems of the body, ox Nyepain Tibetan, are created at varfous stages of development in the womb by an inceraction of our mind's developmental process and the 5 physical elements. 1 The fits, Ling (Wind), creates an enormous number of [ fumetions, the best exarnple of which is elrculation, Ling gives rise fo and regulates the movement of blood, nerve impulses, thoughts in our minds, and food through the digestive tract and eliminative organs. The mind expressed as attachment, desire, or a materialist worldview is manifested during the pre- natal period chrough the development ofthe system of Ling. ‘The second, Trpa (Bile), gives rise to and controls such func- tions as metabolism, liver fonction, and vision, allowing our mind to function with diseriminating intellect. The mind expressed as aggression hatred, or anges is manifested during the prenatal period throagh the development of the system of Trip, Finally, Badd QPhlegmn) creates the physical principle by ‘wich energy can be used to produce a function, provide our body's lubrication, break down foad at the initial stages of diges- tion, ereate che wil, and facilitate memory. The mind expressed asignorance or incomprebesion is manifested during the prena- tal period through the development of the systern of Bédtén Good diagnostic skills the Tibetan system require both —] ‘an ncellectual understanding ofthe genesis and nature of the 3 ‘Nyepa as well as a subjective appreciation of their qualities and functions, Such grounding in the system allows us to avoid a formulaic use of the theoretical and practical aspects of the diagnostic technique. To take a siroplistic or ideologically Leound approach is a mistake, because it weakens our capacity to diagnase illness properly, especially in cases of covoplex or chronic illnesses. It also prevents us from seeing where simple solttions—auch as changes in behavior, lifestyle, or diet—can bbe most atfective, ‘e's harmful to create a significant dichotomy between what ‘we practice in our own life and what we preaeh in a professional ‘context I is moet baneficlal co patients when doctors develop a ‘healthy lifestyle consistent with their understanding of medicine. Such 2 personal practice leads to a deaper understanding of how the action ofthe mind—manifested in one's psychologeal state ox behavior, including dietary habits—is the primary cause of liness and therefore shouldbe the primaty basis of treatment. ‘The practitioner of natural medicine who is ideologically constrained by a purely quantitative approach will often think i 1 disease oriented model mote approprizte to che Western med- ical system. A clear understanding of and personal experience ‘with the principles of health and illness are necessary to develop the capacity to make a diseriminating diagnosis. When the doe- tor achieves this capacity, treatment will be appropriate to the condition. [t will be based on the use of spiritual, behavioral, psychological, and dietary approaches to affeet the root cause of the condition. Then, if tls relevant to the individual case, herbal medicines ot physical treatments (eg, acupuncture) can be cemplosed, This procedure allows the doctor and the patlent to avoid overdependence on therapeutic techniques or devices. in the 4 primary Tibetan. medical texts (rGyud Zhi") the steverare ofa trees used as a teaching metaphoc. Adopting that metaphor here, the roots of Tibetan doctors’ practice consist of their spiritual practice, their understanding and study of the ‘medical teachings, and their own personal life experience. The trunk of the tree fs che capacity to fully understand the nature of ‘health and illness. The branches and the leaves are the specific details of medical theory and practice, and the faite the ability ‘tm makea good diagnosis. SPEAKING, TOUCHING, AND LOOKING ‘Through spictual practic, intellectual training and intotion, the doctor creates the foundation for the practice of diagnosis. The ‘Tibetan mediea! diagnosis consists of 3 man phase. The fists the patient interview, the second is the observation of the urine; the third isthe taking ofthe 12 pulses, after which the doctor may look atthe sclera ofthe eyes and the surface ofthe tongue, and may fee! for sensitivity on certain points of the body. igute 1, fiom a 17th- ‘century woodcut, shovrsa Tibetan doctor taking a pulse) Pulse reading and urinalysis require years of theoretical study along with direct instruction by a master. Both of these diagnostic practices combine the art and the science of medi- cine. The reading of the 12 pulses isa subtle process that Is best ‘Song to the Distont Mountain: Digs in Tein Mcne ALTERNATIVE THERAPIES, MARCH 1999, VOL S,NO.2 53FIGURE 1. Tibetan doctor taking a pulse (17thecentary woodcut) conducted ifthe patlent has not done anything to grossly disturb his or her physical energies. The patient should prepare for the pulse reading by avolding foods and bchavios tbat are excessive- ly heating or cooling co the body as well as anyehing that dis- turbs the circulation. Behaviors or dietary practices that distort