Billy, Don't Be A Guru

Safety requires transparency, and transparency requires that we actively and intentionally disengage from the role of Guru in our patient relationships.

Most of what I find useful in my acupuncture practice I learned on the job, after I graduated from school, and from colleagues: how to treat pain using the balance method, how to handle a ten-pack of needles without dropping them, how to place blankets on someone after they’re needled, and how to talk to patients about a treatment plan they can manage. One exception is how to read a patient’s tongue and pulse. This is some of the most super-cool stuff I learned in acupuncture school. It’s also really unusual, you might say foreign, to many Americans, and that makes it prime territory for some serious othering. At best, we can encounter this type of specialized diagnostic skill with curiosity, respect, and an open mind. At worst, we can indulge a kind of fetishistic orientalism where we see it as exotic and project onto the tradition an aura of mystery, power, and prescience. And by “we,” I mean both patients and practitioners. When acupuncturists take advantage of this projection of mysterious authority and power by assuming the role of Guru, that’s where safety can be compromised.

If patients expect that we can gather information from their tongue and pulse that they do not otherwise have access to, we run the risk of nurturing an authority problem. Here it’s helpful to remember the difference between signs and symptoms. Signs are things the practitioner notices through direct observation of the patient or things that can be objectively measured, like via a lab test. Symptoms are things the patient reports. I can see if a patient is sweating; that’s a sign. I cannot see a headache; that’s a symptom. Placing my fingers on a patient’s wrist to take a pulse and using my eyes to look at a patient’s tongue to get diagnostic information are two ways of gathering signs.

We are gathering signs all the time: I notice the pace at which a person enters the treatment room, if they grimace while settling into the recliner, or if they are wearing more or less clothing than other people are, based on the season. The flow of information that can help me choose points for treatment starts from the moment the patient comes into my awareness, even if it’s my peripheral awareness because I’m working with someone else. But none of this is obvious to the patient. Not like when I ask to see their tongue or to place three fingers on their radial pulse. Also, none of the example signs I mentioned above is definitive. They all suggest things to me that I then need to confirm by interviewing the patient about their symptoms. I need to seek more information from the source: the authority. The same is true of tongue and pulse.

If I’m taking a pulse, you can bet I’m stalling. Which is fine. I rarely take a pulse, and when I do it’s because I’m stumped: not sure which direction I want to go with the treatment, looking for another clue and taking a moment to let all of my impressions settle and coalesce into a clinical picture. It’s all back-of-brain type stuff while I sit with my fingers on the pulse. Because it’s all processing quietly in the back of my mind, I can ask more questions while my fingers are gathering that info.

One question I’ve learned not to ask while I’m taking a pulse: “Is there any chance you’re pregnant?” I’m sorry to say that I freaked out at least two patients before I learned not to DO that. The patient thinks I’ve got some inside info that I’m reading off of their pulse. And they’re not wrong to think that: pregnancy does have a special pulse quality (called “slippery”). But I would never, EVER presume to suggest to a patient that I had some intimate knowledge of their body that they: A. did not have or B. weren't ready to share. We have tests for that sort of thing. And I’m not THAT good with pulses. I’m usually just checking to get a general sense for how tired or wired (or both) a patient is. The few times I asked it were because I was starting to think about treatment points, and there are a couple of points I wouldn’t do on a pregnant person.

The freaked-out patients taught me something important, though: unless I am very intentional and clear, patients may suppose that I know more about what is happening in their bodies than they do. And that, to me, seems like dangerous territory. To safely treat people, I need all four lanes on the communication highway to be wide open and flowing freely - in both directions. And I need the authority to rest with them. I need patients to be the ones determining if they are getting better, and reporting to me how their symptoms are shifting and changing. For sure, I can also reflect back signs that I see and verify their symptoms: “Hey, I noticed you’ve been talking about gardening a lot - are your knees doing better?”

One more example: Diagnostic inspection of the tongue is another distinct feature of Chinese medicine, and one I use even less often than pulse-reading. I trained in herbal medicine as well as acupuncture when I went to school, so I sometimes prescribe herbs for people. Mostly I use the tongue to help guide an herbal prescription. Every so often, though, I may have a hunch that a patient’s constellation of symptoms may be related to anemia. There are sometimes visible signs on the tongue that can suggest that, as well. Anemia is not something acupuncture is great at helping with, and it’s also really important to know if it’s primary anemia (see your doc, take some iron, feel better, yay!) or if there’s bleeding going on somewhere that a patient should get medical attention for. So in those cases, I’ll ask a patient to stick out their tongue. And that’s weird. So I owe them something in exchange for participating in this invasive and odd ritual. And that something is a few words about why I was looking and what I saw. “Ok, looks good. Have you ever been checked out for anemia? I’d probably check that out if I were you, with your fatigue and insomnia, and your tongue looks a little pale to me.” Not providing this type of transparency would be, to me, to engage in Guru behavior. And if I can’t say what I was looking for and what I found in a way that makes sense to the patient, then I really have no business asking them to engage in this weird diagnostic ritual. I don’t want to risk the “I know something you don’t know” dynamic that places inappropriate authority with me as a practitioner with my “objective” signs, and de-emphasizes the patient’s subjective symptoms - the critical source of information for delivering a safe and effective course of treatment.

It's also worth noting that before taking a pulse or examining a patient's tongue, I'll secure consent to do this type of more invasive "looking." Active consent is one more tool to help keep the power appropriately balanced.

(Unfortunately, it’s necessary to mention that there’s a style of “practice management” that shall remain nameless, that’s several standard deviations beyond sketchy, that involves acupuncturists deliberately exploiting imbalances of safety and authority for financial gain. It looks like this: the acupuncturist takes a patient’s pulse, puts on a look of great concern, and then tells the patient that the “imbalances” they’re feeling mean that the patient desperately needs acupuncture, a lot of acupuncture, a lot of expensive acupuncture, and in fact here’s a contract for an entire course of treatment -- payment due up front -- which the patient needs to sign right now, if they value their health. Patients have taken out second mortgages on their houses in response to this kind of pressure (“don’t you want to see your children grow up?”); though sometimes the acupuncturist with the amazing pulse-reading skills also just happens to have the ability to sign patients up on the spot for a special new credit card. At least one acupuncturist has lost his license in part due to these kinds of shenanigans. Gurus can be very, very bad news.)

There’s one more subtlety to the question of authority and safety I want to discuss. It’s about patients who require me to hold a fair amount of authority so that they can feel safe and become regular users of the clinic. In general, I have encountered this more often amongst my older patients, especially those born in the 1930’s, in particular. Early in my practice, I had the most difficulty finding rapport and a good, easy flow with these patients (who were in their 80’s at that time). I had a casual clinic environment. I wore t-shirts and jeans to work. My recliners were covered in mismatched floral-print thrift-store sheets. I was very comfortable in my clinic. Many of my older patients were not. I would invite them to choose their own chair, and this caused distress and confusion. I would tell them to let me know when they were done and wanted their needles out, and this generated mistrust. They needed more authority from me so that they could be comfortable. They needed to know that I knew what I was doing. It took me a long time to recognize this and even longer to develop the flexibility to give them what they needed so that they could relax. Eventually, I learned to see when a patient needed this alt-persona from me. I would say “Sit there,” and “I’ll pull your needles in 30 minutes,” and “Come back next Tuesday and Thursday. Make your appointments on the way out.”

That last bit, the treatment planning, is something I normally do in a much more collaborative way - unless the patient can’t tolerate it. With patients who need me to be more directive, I check in very carefully about their symptoms and their progress, because I know that it’s my job to tell them when they’re done with treatment or if/when they do not seem to be getting better and it’s time to try something other than acupuncture. With most of my patients, I build a trusting relationship where those decisions get discussed and we both have input, intuition, and information to offer. With most patients, the power dynamic is more balanced, and if I’ve done a good job keeping the information flowing both directions, the conditions are good for a very safe course of treatment and a socially safe continuation or discontinuation of treatment. With others, particularly elders, the potential to abuse their trust is very high, and so it’s critical not only to be diligent about surveying their symptoms and progress, but in handling the treatment planning process with appropriate care for the patient’s social safety. That’s authority without Guru status.