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“A doctor is intention.”
What is intention? What is悟性 (悟性, insight)?
“A doctor is intention,” a phrase almost every student of Traditional Chinese Medicine (TCM) has heard, and悟性 (insight) often becomes one of the barriers on the path to learning medicine. What is intention? What is悟性 (insight)? Perhaps no one can give a universally convincing answer. To be frank, I have never considered myself to have悟性 (insight) in learning medicine. In my process of studying TCM, the only thing relating to悟 (enlightenment) might be comparative analysis: comparing the earlier and later discussions and prescriptions in the works of the same physician; comparing related discussions and prescriptions for the same disease/syndrome/symptom by different physicians within the same school; comparing the related discussions and prescriptions by different physicians for the same disease/syndrome/symptom, hoping to find commonalities and specific applicable conditions by preserving common ground while reserving differences, and transforming these experiences into personal knowledge. However, this might have little to do with悟性 (insight) in the traditional sense of learning TCM, and is more a form of diligent effort. My master’s and doctoral supervisor, Professor Zhao Jinxi, once said: “If you feel someone has studied the Treatise on Cold Damage (《伤寒论》) better than you, that person must have put in at least ten times the effort you did on the Treatise on Cold Damage.” If the other person had only studied a little more than you, you wouldn’t feel a difference between you and him. So many times, when teachers say a student understands at once, it is probably because the student already had a relevant knowledge reserve beforehand. After all,悟性 (insight) is hard to suddenly improve or appear from nowhere; a sudden悟 (enlightenment) is something that is rare and cannot be forced. What we can do is continuously improve our knowledge base and strengthen our abilities, and seize the opportunity when悟性 (insight) is possible to increase. Therefore, overemphasizing悟性 (insight) may be just an attempt to mystify, and using lack of悟性 (insight) as an excuse to slack off may be just self-comfort.
Nowadays, there are many so-called TCM dream mentors claiming to be ancient or supernatural masters. You sign up, pay, gain悟性 (enlightenment), and can immediately use what you learn in clinical practice, instantly improving clinical skills. Do these ancient books really survive in their hands or by oral transmission for thousands of years? Did Bian Que appear in a dream granting them inner vision? Yet these courses run session after session, and no one has fully replicated the abilities of these dream mentors. So it’s said that悟性 (insight) is insufficient, enlightenment hasn’t come yet, or that training is needed, and so on. I have always believed that if medical knowledge requires悟 (insight) to understand and apply, that knowledge itself might not be mature or complete enough. Rather than spending a lot of time or even money to悟 (enlighten) on knowledge you might never悟 (enlighten) to, it’s better to start learning the classics of TCM and the diagnostic and therapeutic experiences of past physicians, learning this tangible and perceptible knowledge first. Because human time is limited, especially for TCM students, the time they can truly settle down to read might only be during undergraduate studies — graduate studies bring standardized training, research pressures, and graduation pressure. TCM students, especially undergraduates, should do the right thing at the right time to achieve twice the result with half the effort, first grasping solid and practical content, and only with spare energy pursue so-called secret techniques.
Here I must mention one of Professor Lü’s teachers — Professor Qin Bowe, one of the Three Outstanding Scholars of Shanghai. Professor Qin was the most respected physician of my grandfather, bar none. In my freshman year, thinking I had grasped the basics of TCM theory, I asked my grandfather if he had recommended extracurricular books. Without hesitation, he said, “Professor Qin’s ‘Qianzhai Medical Lectures’.” Over the last eleven years, my grandfather has recommended me three extracurricular TCM books; this was the earliest and most recommended. Indeed, I have read this book about seven times, covering the entire text with notes in various colored pens. Professor Qin proposed many thought-provoking ideas in this book. One roughly said that we must value specialized prescriptions or so-called secret methods for specific diseases, but we cannot rely solely on specialized prescriptions while neglecting our own TCM thinking, otherwise it’s the divine prescriptions curing diseases, not us curing diseases. This is a fast-paced, information-exploding era; everyone wants to achieve their goals quickly, well, and efficiently. Especially for TCM, which traditionally requires years, even decades or lifelong learning, every student wants to master independent clinical skills in the shortest time. Basic knowledge accumulation is often tedious and uninteresting; clinical secret techniques and specialized prescriptions are often convenient and enjoyable because they don’t require additional integration or digestion but can be directly applied to specific clinical situations. But as Professor Qin said, is it really us treating the disease, or are those divine prescriptions and secret methods treating the disease? Of course, this is not to deny specialized prescriptions and secret techniques but to view dialectically the relationship between syndrome differentiation, respect for disease mechanism, and secret techniques. Do not neglect tedious accumulation of basic knowledge, nor excessively focus on convenient and efficient secret prescriptions. Instead, on the basis of solid and classical foundation and constructing and perfecting one’s own TCM clinical thinking, broadly learn all methods beneficial to treating patients’ diseases, including specialized prescriptions and secret techniques. When teaching undergraduates, I often joke that if we only learn these secret techniques, there’s no need to graduate high school; kindergarten level would suffice — what disease or symptom, use which formula or operation, like connecting dots on a picture, kindergarteners could do it.
“Doctor is intention” also refers to the magic brushstrokes a physician applies in clinical prescription and diagnosis beyond悟性 (insight). Many say that in TCM clinical prescriptions, it often relies on feeling—an indescribable feeling, a feeling requiring years of accumulation, or a feeling emerging after personal悟 (enlightenment). Many students in clinical teaching rely on feeling to diagnose, differentiate syndromes, choose prescriptions, and select herbs. People often say, “I feel he should use this formula / I feel he should use these herbs,” but when further asked, they often cannot explain the real reasons for those choices. I do not quite advocate relying on feeling or悟性 (insight) to diagnose because feeling that a certain prescription or herb should be used is not precise, may be biased, and can be accidental. If you do not even know why you make that diagnosis, select that formula, prescribe that herb, or choose that dosage, even if the treatment works well, this feeling is hard to replicate. Diagnosing this way, even if you burn the midnight oil every day, you will fail to improve effectively. Therefore, during every teaching session, I emphasize repeatedly that diagnosis cannot rely on feeling; there must be evidence, and one must distinguish between clues and evidence. When diagnosing, ask yourself why you gave this diagnosis, differentiated this syndrome, chose this prescription, used this herb, and that dosage. First you must convince yourself, only then can you convince the patient. Understanding why you do this allows you to know where you are right or wrong upon feedback. What is the basis of differentiation? Combine the patient’s current four diagnostic methods information, past medical history, auxiliary examinations, what evidence supports your pathomechanism-based syndrome differentiation and treatment result? What evidence does not support it? What are contradictory? Is supported evidence more or unsupported more? Use overlapping mergers, causal explanations, reverse transformations, or is it inexplicable? Sometimes what looks contradictory is the key to unlocking the essence of the disease. Do not rush to explain contradictions with overlapping mergers. If TCM students new to clinical work analyze in this way, they will definitely draw the relatively “correct” result under current knowledge reserves. Of course, the “most correct” here may not be the final correct answer, due to limited knowledge reserves, occasional lack of understanding about the pathomechanism behind some four-diagnostic data, or unfamiliarity with some decisive knowledge points. But as knowledge reserves and clinical practices accumulate, they will gradually reach a more accurate treatment plan.
Furthermore, we must pay attention to the distinction between clues and evidence. In my undergraduate years, I heard an expert say that diagnostic accuracy could be described as follows: Suppose each person using a certain method of differentiation has 90% accuracy. For instance, if a syndrome uses a formula corresponding to those symptoms, accuracy is 90%. If you first use zang-fu (organ) differentiation, then qi-blood-fluids differentiation, then eight principles differentiation, the accuracy is 90%*90%*90% = 72.9%, which is much lower than directly syndrome-formula correspondence. My younger self was confused and almost laughed out loud. Now, some classical formula scholars excessively enlarge the concept of focusing on chief symptoms / differentiating formula syndromes, ignoring the disease behind the symptoms and pathomechanisms behind the disease, infinitely enlarging the indications of chief symptoms. For example, seeing epigastric fullness and non-remitting hiccup just using Xuanfu Daizhe Tang; chest obstruction and qi rushing upwards just using Ling Gui Zhu Gan Tang; irritability and inability to lie down just using Huanglian Ejiao Tang, without analyzing the causal relationships of patients’ complex symptoms, simplifying everything as combined diseases, as if it’s always six-channel combined disease. I personally prefer to regard these typical symptoms as clues. Seeing epigastric fullness and non-remitting hiccup might suggest the possibility of choosing Xuanfu Daizhe Tang; following this clue, one should analyze whether the patient fits the pathomechanism of Xuanfu Daizhe Tang, i.e., spleen and stomach deficiency or spleen-stomach qi mechanism disorder, which I regard as evidence for selecting Xuanfu Daizhe Tang. If the correspondence is one-to-one from symptom to formula, it is essentially no different from divine prescriptions curing diseases or connecting dots in a drawing. So clues are important, but evidence is even more important. Clues should not be mistaken for evidence, nor should feeling be evidence. Evidence should be based on the patient’s four diagnostic information, past history, auxiliary examinations, TCM classics, effective experiences of historical physicians (including teachers you have shadowed), and even your own past experiences, but not merely feeling. Of course, it cannot be denied that for some rare and difficult diseases, evidence may be unavailable, and diagnosis relies on analogy and feeling. Because of this, the diagnostic process finding evidence for common, chronic, and frequent diseases forms the important foundation for reasonable analogy and reaching reliable feeling when treating rare and difficult diseases.
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