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SEEING TO THE DISTANT MOUNTAIN:
Diagnosis In Tibetan Medicine

Eliot Tokar


1999 Innovision Communications

Originally presented on April 29, 1997 to the Roundtable On Traditional Medicine, convened at Columbia Presbyterian Hospital, New York City.
Published in the March 1999 issue of Alternative Therapies In Health And Medicine Volume 5, No. 2.

~~ARTICLE CONTENTS~~
1. Introduction
6. Seeing To The Distant Mountain
2.

Learning To See
   
3.
Like A Rich Man With One Child
7. Acknowledgments
4.

The Root, the Tree, The Branches,
The Leaves, The Fruit

8. References
5.
Speaking, Touching and Looking
9. Additional Readings




Introduction

When most patients seek a doctor for a medical diagnosis, they generally assume that the process will clearly and directly reveal the truth about their condition. Their assumption is that the diagnostic procedure will reveal their illness in much the same way that cutting open an apple bears its core. In most cases, however, nothing could be further from the truth.

In examining the nature of diagnostic procedures, it is worthwhile to recall the Indian tale of the blind men who 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. None 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 trunk, the tail a rope, the trunk a snake, and so on.

In medical diagnosis we healthcare practitioners begin with our biases, based on our personal, cultural, and professional world view, 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 then attempt to comprehend the truth of the condition.

If we are to succeed we must do better than the blind men of the tale. By experiencing the trunk, leg, or tusk, we must be able finally to perceive the whole. We must ultimately have the insight and skill to see the entire elephant. However, and because of the blindness inherent in the prejudices and limitations of any world view, we inevitably see a slightly or even radically different elephant.

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Learning To See

In the teachings of Tibetan medicine there is a metaphor that refers to the stages of development of the diagnostician. At the first level a student of medicine is likened to a person standing 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. At a higher level the student can perceive that someone is standing on the opposite peak but he or she still lacks the ability to perceive anything about that person. At many succeeding levels, more and more can be perceived about this person until, ultimately, at the most advanced degree of ability, the student recognizes precisely who is there.

This metaphor describes the evolution of perceptive abilities in learning Tibetan medical diagnosis. Its meaning can also apply to the gradual process that practitioners of different medical systems must be undergo to truly perceive what a doctor from another scientific world view sees. Performing a medical diagnosis requires an understanding of the technique and language of the system within which one is operating. The foundation of diagnostic skill, however, is the development of a capacity of awareness that leads to clear and precise perception.

The following article will explain the basic tools and language 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 truly complementary approach to medicine, there must be a common language created through which traditional and allopathic doctors can effectively communicate about their disciplines. Medical traditions are not the sum total of their diagnostic or treatment techniques; instead, they are the result of the scientific, cultural, and spiritual 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 surgeon and Yale professor, Richard Selzer, MD.1 In this book Dr. Selzer recounts a diagnostic session performed by my first teacher, Dr. Yeshi Donden. The session was part of a demonstration conducted at an American hospital. Dr. Donden was shown a patient about whom 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 had a chronic heart problem. He diagnosed an imbalance in the basic circulatory principle of the body as it relates to blood and heart function. This disorder had progressed to a stage in which it affected the patients pre-existing heart irregularity, which had developed during a specific stage of embryological development. Dr. Selzer1 recounted the diagnosis in this manner:

"[Dr. Donden] speaks of winds coursing through the body of the woman, currents that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charge the full waters of her river, as the mountain stream cascades in the springtime, battering, knocking loose the land and flooding her breath."

The allopathic diagnosis had been "congenital heart disease", an "interventricular septal defect, with resultant heart failure". 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 as a largely divine mystical experience accessible to priests but not to mere doctors.1 Interest, fascination, and perhaps even respect were engendered, but little understanding between the doctors seems to develop. In fact, what Dr. Donden was doing was not magic. He was doing what is expected of a properly trained Tibetan physician, albeit at its highest level.

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Like A Rich Man With One Child

In describing how he worked as a physician, my teacher, Dr. Trogawa Rinpoche,2 remarked: "my external activity is the practice of medicine, and in my inner thoughts I meditate on the Medicine Buddha". This comment does not simply tell us that Dr. 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 is an ongoing practice toward spiritual development and its resultant awareness and intention, toward which the physician continually strives. Given the differing levels of practice and development that exist among Tibetan doctors, there is no quantitatively prescribed standard for this aspect of medical practice. Still, the primary classic principle of Tibetan medical practice is that the bedrock of one's approach to diagnosis lies within the doctor's spiritual practice.

In describing the Tibetan approach to diagnosis it is vital to understand how the properly trained Tibetan doctor sees the world. After all, it is always within a doctor's subjective understanding of the nature of the phenomenal world that the relatively objective work of obtaining a diagnosis occurs. How, then, do Buddhist teachings determine the basis for making a clear diagnosis of illness?

Because the historical Buddha described his role and teaching in a fundamentally medical fashion, this connection is very direct. In fact, because the Buddha's teachings were meant to cure suffering, he was known as "The Supreme Physician".3 The Buddha is therefore a direct inspiration for Tibetan doctors, who attempt to emulate this model of a spiritually 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 is important to comprehend that doctor's conscious intention.

Buddhist teachings delineate Tibetan doctors' image of themselves and their patients as well as the doctor-patient relationship. Buddhism's central teachings and practices place great emphasis on (1) understanding and discovering the nature of one's mind, and thereby transcending ego; (2) developing a practice of compassion toward all other conscious beings; and (3) developing a sense of equanimity. Therefore, for the doctor of Tibetan medicine there is no psychological or professional dilemma in directly identifying with his or her patient -- as there can be, for instance, in Western medicine. In a sense, the Tibetan physician intentionally seeks to identify with the patient. It is important for us as physicians to intimately understand the basic nature of suffering -- both the patient's and the doctor's -- as well as to understand that our relationship to the patient has both a professional and spiritual significance.

Through spiritual practice the Tibetan doctor is trained to emulate a highly spiritually 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". Bodhisattvas are spiritual trainees who strive to generate an altruistic mind of love and compassion.4 They are basically Buddhas in the making who have dedicated their pursuit of spiritual awareness to the single goal of bringing about the welfare of all.

We can get a glimpse of the professional ethic Dr. Trogawa endeavors to practice in an instruction from the Buddhist sage Vimalakirti:

...I am ill because all sentient beings are ill. If the illness of all sentient beings were to come to an end, then my illness would be ended. Why is this so? Because when the Bodhisattva enters into the realm of birth and death for the sake of beings, he becomes subject to the laws of this realm and thereupon becomes ill. If all sentient beings were to be cured of their diseases, then the Bodhisattva would never be ill again.

It is like the rich man who only has one child. When his child becomes ill, his parents become ill. If the son is cured of disease, so also are the parents. It is the same for the Bodhisattva: he loves all beings as if each of them were his child. When all beings are cured, then the Bodhisattva will be cured....
3

Before seeing their first patient, Tibetan doctors practice an archetypal diagnosis that becomes a basis for 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 suffering and all of the innumerable diseases they may have. The Medicine Buddha feels anguish for them and wishes them freedom 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 reality, as understood from the Buddhist perspective.

The resultant confusion leads to activities of our body and mind which directly or indirectly lead to suffering and illness. Given this diagnosis, the Medicine Buddha understands the temporary, illusory nature of illness. Pushing through his sense of anguish, he delves deeper into this and sees that within every atom of every being who appears as suffering, there exists a Medicine Buddha. He experiences inner joy in the knowledge that despite suffering, there is the potential for boundless happiness. Having completed his diagnosis, the Medicine Buddha projects a purifying energy from himself to those before him that reveals their inherently healthy state.5

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 this emptiness, all the forms and concepts we occupy in life -- including illness -- are understood as illusory, dream-like and therefore highly changeable. Thus, it follows that illness is made worse or better by changes in the mental perception we give it.

The Medicine Buddha's profound diagnostic skills are derived from wisdom based on deep awareness and perception. These qualities, along with his resultant capacity to heal, makes him the role model for the physician of Tibetan medicine By visualizing themselves as Medicine Buddha, doctors of Tibetan medicine pursue an aspiration to develop the same capacity for compassion, awareness and skillfulness. This process is the root from which diagnostic skill develops. It is established even before the first patient walks in the door.

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The Root, the Tree, The Branches, The Leaves, The Fruit

All medical systems grow from three roots: (1) Faith and Belief, (2) Experience and Perception, and (3) Objectivity and Analysis.6 Western 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 movement becomes a prominent force, Western medicine is beginning to grant some significance to these two other roots. Examples of this are Larry Dossey's7 and Herbert Benson's8 work on the value of faith and belief in treatment, and Oliver Sack's9 assertion that the subjective experience of the patient is a useful tool in diagnosis. Practitioners of Tibetan medicine have always depended on all three roots to properly perceive and analyze an illness and its cause in the diagnostic setting.

By synthesizing knowledge from various medical systems, Tibetans created a systematic approach to medical science drawing from thousands of years of accumulated empirical knowledge and intuition about the nature of health and illness. Centuries ago, before Buddhism entered Tibet, Tibetans like all ancient people, had a significant degree of medical knowledge. According to traditional sources, in the beginning of the 4th century many new ideas regarding medicine began to enter the country. At first, influences came from India in the form of what is now called Ayurvedic medicine, as well as more spiritually and psychologically based systems from Buddhist and other sources.

Around the 7th-8th centuries 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 of illness. Those with superior abilities in the diagnosis, treatment, and understanding of illness were invited to stay and contribute to the country's medical knowledge base. In the 11th century, this knowledge was codified into a unique system.10

To properly perform Tibetan medical diagnosis, a doctor must have an understanding of the theories of Tibetan medicine and their unique description of the body -- its creation, principle energies, functions, and processes -- as well as an understanding of health and the etiology of illness. As with Western medicine, the quantitative aspect of knowledge in medicine must be understood 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 are 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, a microcosm directly related to the macrocosm of the natural world.

All of the material which makes up our universe is based on the qualities of 5 basic elements, which are described in the ancient physics depicted in Tibetan medicine. Like all traditional 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 human organism. Tibetans defined the qualities of the basic forces which exist in nature in the theory of the five elements. These forces are named for their most identifiable manifestations: earth, water, fire, wind, and space. The characteristics (such as a substance's taste) and therefore the nature of all matter then result from the qualities of these elements individually or in combination.

Earth has qualities of firmness and stability and therefore provides the basis of physical existence and development. Water creates moisture, giving rise to all fluids. Wind creates movement and so enables all aspects of circulation and movement. Fire creates transformation, metabolic functions, and activity. Space provides the potential for existence to be created in the first place. Combinations of these qualities make up the physical aspect of our bodies as well as the body's distinct physiological energies.5

As with any medical system, understanding the various functions of the body is important in Tibetan medicine. However, the underlying physiological principles that create and maintain those functions are of primary importance. Tibetan medicine defines three main systems which control all the body's functions. These three systems of the body, or Nyepa in Tibetan, are created at various stages of development in the womb by an interaction of our mind's developmental process and the five physical elements.

The first, Lng, (Wind), creates an enormous number of functions, the best example of these functions is circulation. Lng. gives rise to 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 prenatal period through the development of the system of Lng.

The second, Tripa, (Bile), gives rise to and controls such functions as metabolism, liver function, and vision, allowing our mind to function with discriminating intellect. The mind expressed as aggression, hatred, or anger is manifested during the prenatal period through the development of the system of Tripa.

Finally, Bdkn , (Phlegm), creates the physical principle by which energy can be used to produce a function, provides our body's lubrication, breaks down food at the initial stages of digestion, creates the will, and facilitates memory. The mind expressed as ignorance or incomprehension is manifested during the prenatal period through the development of the system Bdkn.5,12

Good diagnostic skills in the Tibetan system require both an intellectual understanding of the genesis and the nature of the three 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 simplistic or ideologically bound approach is a mistake, because it weakens our capacity to diagnose illness properly, especially in cases of complex or chronic illnesses. It also prevents one from seeing where simple solutions -- such as changes in behavior, lifestyle, and/or diet -- can be most effective.

It is harmful to create a significant dichotomy between what we practice in our own life and what we preach in a professional context. It is most beneficial to patients when doctors to develop a healthy lifestyle consistent with their understanding of medicine. Such a personal practice leads to a deeper understanding of how the action of the mind -- manifesting in one's psychological state or behavior, such as dietary habits -- is the primary cause of illness and therefore should be the primary basis of treatment.

The practitioner of natural medicine who is ideologically constrained by a purely quantitative approach will often think in a disease-oriented model more appropriate to the Western medical system. A clear understanding of and personal experience with the principles of health and illness are necessary to develop the capacity to make a discriminating diagnosis. When the doctor achieves this capacity, treatment will be appropriate to the condition. It will be based on the use of spiritual, behavioral, psychological, and dietary approaches to affect the root cause of the condition. Then, if it is relevant to the individual case, herbal medicines or physical treatments (e.g. acupuncture) can be employed. This procedure allows the doctor and the patient to avoid over-dependence on therapeutic techniques or devices.

In the four primary Tibetan medical texts (rGyud bZhi12) the structure of a tree is used as a teaching metaphor. Adopting that metaphor here, the roots of Tibetan doctors' practice consists of their spiritual practice, their understanding and study of the medical teachings, and their own personal life experience. The trunk of the tree is the 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 fruit is the ability to make a good diagnosis.

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Speaking, Touching and Looking

Through spiritual practice, intellectual training, and intuition, the doctor creates the foundation for the practice of diagnosis. The Tibetan medical diagnosis consists of three main phases. The first is the patient interview; the second is the observation of the urine; the third is the taking of the twelve pulses, after which the doctor may look at the sclera of the eyes and the surface of the tongue, and may feel for sensitivity on certain points on the body.

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 medicine. The reading of the twelve pulses is a subtle process that is best conducted if the patient has not done anything to grossly disturb his or her physical energies. The patient should prepare for the pulse reading by avoiding foods and behaviors which are excessively heating or cooling to the body as well as anything that disturbs the circulation. Behaviors or dietary practices that will distort or discolor the urine sample are avoided as well.

For 24 hours before the appointment, patients should take no medication (except prescription pharmaceuticals, which cannot be stopped abruptly), red meat, alcohol, beets, coffee of any kind, black tea, or foods that are unusual to their normal diet. They should also abstain from strenuous physical activity and sexual activity. No vitamins should be taken for 2 days prior to the appointment. Hot showers and baths should not be taken on the morning of the appointment. Patients are advised not to ingest anything except water on the day of the appointment; or, if they must eat, to eat light, easy to digest foods at least 2 hours prior to the appointment.13

The patient is asked to bring a urine sample which should be taken from their second urination after midnight. Although, most doctors ask simply for the first morning's urine, my teacher Dr. Trogawa Rinpoche states that such a sample could have too many influences from the food consumed the previous evening. If the patient goes to bed after midnight and/or wakes up during the night to urinate, the first sample taken in the morning upon arising can be used. Otherwise, the person should be asked to bring in the second sample taken in the morning (any time after 4 PM). Because of the significant effects of temperature on the urine, the patient is asked not to refrigerate the sample.13

When the patient arrives, the physician tries to discover as much as possible about the problem through listening and observation. The first step in the interview is observation of the patient's physical appearance and manner of speaking. This is most useful if one understands the nature of the three Nyepa and the classical physical and psychological types which can result from a constitutional predominance of one or a particular combination of these energies. The physician inquires about the patient's current medical condition as well as how the patient feels personally. It may be useful to investigate the patient's medical history, health relative to the seasons, dietary pattern, or to engage in a more detailed discussion of personal or spiritual issues. It is useful to ask female patients about their gynecological health and history and their experience with childbirth. Each of these items provides a quantity of health information as well as a basis to understand the nature of their condition vis--vis the five elements and three Nyepa.

The patient's dietary history can be especially revealing for two reasons. First, following behavior, diet is a primary determinant of health. Second, there is a great amount in the Tibetan medical literature about the meaning and significance of foods and the six tastes (salty, pungent, sour, bitter, astringent, sweet) with respect to the theory of the five basic elements. Understanding a person's dietary habits and reactions to different foods can reveal the basis of their condition as well as the circumstances leading to illness.

The manner in which these factors can result in illness will be more or less complex depending on the acute or chronic nature of the problem. All illnesses must be seen as individual and based on a patient's background. There is a widespread notion that allopathic medicine only addresses symptoms, whereas natural medicine only addresses the root cause of illness. This is incorrect -- an exhaustive list of symptoms is crucial to a proper diagnosis in Tibetan medicine. If one sees ten different cases of what allopathic medicine would regard as one disease, the additional accompanying symptoms (physical and/or psychological) will determine the specific diagnosis in terms of Tibetan medicine. Once the full range of symptoms in the context of the patient's history is discovered, the root cause of the illness can begin to be understood. Within the one disease defined by allopathic medicine, the Tibetan physician might in fact define ten different sets of symptoms, ten different etiologies, and therefore ten different illnesses. The root cause of the patient's entire complex of symptoms is ultimately diagnosed and treated.

After interviewing the patient, the Tibetan physicians analyzes a urine sample in a white opaque container. They begin by observing the sample's odor. Specific odors described in the texts correlate12 with specific conditions. If it is a fresh sample, the presence or lack of vapors helps to define the relative heat/excess or cold/insufficiency manifest in the condition. The specimen is then observed to determine whether it has a watery appearance or shows degrees of the colors yellow, brown, red, and/or white.

Next the physician will determine if the sample has particular characteristics such as whether a reddish ring appears around the surface of the sample. A blackish hue, for example, indicates specific conditions such as the presence of exceptional toxicity in the system. Any deposits in the urine are noted for their specific appearance, location in the sample, and persistence. Numerous types of deposits and their specific pathologic significance are described in the texts. 12

The sample is then vigorously stirred with a stick; the size, color, placement, amount, and persistence of bubbles is observed. The observation of the bubbles provides valuable information regarding the nature of the illness, the presence of infection and the localization of the illness. The four foundational texts of Tibetan medicine, the rGyud bZhi, and their commentaries describe in detail how the diagnostic signs listed above relate to specific imbalances of the Nyepa, individually or in combination.

The effects of organic homeostasis are reflected in the patient's pulse. There are twelve distinct pulses at the radial artery of each wrist. The site of pulse taking should be the distance from the first crease below the wrist on the distal forearm measured down the length of the first phalanx of the patient's thumb. The doctor's fingers are placed flat on the patients wrist, parallel and spaced with approximately the width of a grain of rice between them. This placement is chosen because of its relation to the other arteries in the body. It is a proper distance from the heart and liver and therefore does not have too much or too little influence from the circulatory energy or blood pressure. Blood and the circulatory energy (Lng) from all the organs flow through the distal radial artery, providing information about the patient's condition. Analogous to waves that affect the flow of the ocean, the energy that flows along with the blood exercises its effect in direct relation to the balance or imbalance of the basic three Nyepa that constitute the body.11

The doctor uses his or her index, middle, and ring fingers to feel the pulse. Specific pressure is applied by each finger and each finger is divided in half longitudinally with each side feeling a distinct pulse of a specific organ. With his or her right hand the doctor feels the heart, small intestine (switched to doctor's left hand for female patients); stomach, spleen; left kidney, reproductive organs. With his or her left hand the doctor feels the lung, large intestine (switched to doctor's right hand for female patients); liver, gall bladder; urinary bladder; right kidney).

Pulse taking involves the assessment of the pulse's width, depth, strength, speed, and response to pressure. In the texts there are detailed descriptions of all these qualities and their indication of health, illness, and impending death. The speed of the patient's pulse is counted relative to the physician's respiration rate. Consequently, in performing pulse diagnosis attention to the breath is as significant as it is in meditation.

The pulses are influenced by the seasons, because all physical phenomena reflect their composition in the five elements described above. Each season has a clear elemental nature that relates to the nature of the individual organs. As the function of each organ is affected by the seasons, the pulse takes on specific characteristics during different times of the year. Tibetan physicians must be aware of those changes when taking the pulse.

When the different pulses are properly understood and coordinated with the other investigations described above, one can clearly define the type of illness, its location, its chronicity, its hidden complications and other meaningful aspects of its etiology. To further confirm the diagnosis we can look at the color, shape and coatings of the tongue; the sclera of the eye; and the sensitivity of certain pressure points on the body.

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Seeing To The Distant Mountain

With the doctor solidly rooted in the knowledge and practice of the ecological and spiritual understanding of medicine, and the patient prepared to clearly reveal the nature of his or her condition, diagnosis in Tibetan medicine becomes an elegant investigation into the root causes of illness. The goal of diagnosis, as in meditation, is to gain insight into the true nature of particular phenomena.

This article is not an exhaustive description of the techniques of Tibetan medical diagnosis. Further descriptions are available from published translations and summaries of Tibetan medical texts. Mastery of the diagnostic techniques described in these texts requires life-long study and practice. In this article I have provided an overview and analysis of an approach to investigating illness as taught to me by my teachers over the past fifteen years.

In Dr. Trogawa Rinpoche's clinical approach, the physician arrives at an individualized, complex diagnosis explaining the systemic imbalances that have manifested as illness. A multi-level therapeutic approach is created to treat this imbalance (and significant acute symptoms) in order to achieve a truly curative effect. As modernism affects Tibetan medicine, this more classical, holistic approach to Tibetan medicine is at risk of being lost. The economy of time and commerce can encourage even Tibetan doctors to think in clinical terms influenced by the hegemony of Western medical and technological culture. This type of clinical shortcutting can lead, for example, to an excessive emphasis on the use of herbal medicines to cure a more narrowly defined model of illness.

As health care practitioners it is our job to properly diagnose and then treat illness as effectively as possible. But that process should be an educational experience for both doctors and patients. Tibetan medicine describes a logical structure for understanding a complex matrix of factors resulting in health or illness. It provides a set of diagnostic tools to find the causes of imbalances which result in poor health. Both of these functions are based on a centuries-old tradition of contemplation paired with empirical observation, maintained by a long, unbroken lineage of teachers. Tibetan medicine reminds us what traditional people know: that illness needs to be understood on the basis of the inherent relationship between physical health, psychology, behavior, diet, environment, and our spiritual existence.

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ACKNOWLEDGMENTS

I am indebted to my teachers Dr. Trogawa Rinpoche and Dr. Yeshi Donden for their rare and priceless teaching and as well to my colleague Shakya Dorje. I would also like to thank Prof. Kenneth Zysk for his support and for organizing the Roundtable On Traditional Medicine, at Columbia Presbyterian Hospital, NYC, where this paper was first delivered. I am most grateful to Ariana Vora, Annette Tokar, Brian Tokar and Mike Muscat for their invaluable assistance in editing this work. Finally, thanks to the Hinduja Foundation, and the Rosenthal Center for Alternative/Complementary Medicine for funding the forum at which this paper was originally presented. Finally, thanks to all those at the Alternative Therapies In Health And Medicine journal for all their help.

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REFERENCES

1. Selzer, R. Mortal Lessons: Notes on the Art of Surgery;1987.

2. Rinpoche, T. Ven. Dr. Trogawa Rinpoche: In His Own Words". Howard Beach, NY: Chakpori Corp.;1992.

3. Birnbaum, R. The Healing Buddha. Boston, Ma: Shambhala Publications, Inc.;1989: 14-16.

4. Coleman, G. A Handbook of Tibetan Culture. Boston, MA: Shambhala Publications, Inc.; 1993: 285.

5. Donden, Y. Tibetan medicine seminar. Lectures presented at: American Institute for Buddhist Studies;Fall1983:Amherst, MA.

6. Tokar, E. Seminar in Tibetan Medicine. Lecture presented at: the New York Botanical Garden;November 2, 1996; Bronx, NY.

7. Dossey, L. Prayer is Good Medicine: How to Reap the Healing Benefits of Prayer. San Francisco, CA: Harper Collins;1996.

8. Benson, H. Timeless Healing: The Power and Biology of Belief. New York, NY: Scribner;1996.

9. Sacks, O. Recycling old ideas, new forms. Lecture presented at: the New York Public Library, April 20, 1994;New York, NY.

10. Yonten, P. A History of the Tibetan Medical System. In: Tibetan Medicine. Dharamsala, India: Library of Tibetan Works and Archives;1989; 12:32-51.

11. Rinpoche, T. Introduction to Tibetan medicine. Lecture presented at: the New York Shambala Center;July 1986;New York, NY.

12. rGyud bZhi. Dharamsala, India: Tibetan Medical & Astrological Institute;1994.

13. Rinpoche, T. Preconsultation Instructions. Howard Beach, NY:Chakpori Corp.;1989.

14. Rinpoche, T. Tibetan Medical Dietary Guidelines. Howard Beach, NY:Chakpori Corp.;1992.

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ADDITIONAL READINGS

1. Clifford, T. Tibetan Buddhist Medicine and Psychiatry. York Beach, ME:Weiser;1990

2. Thondup, T. The Healing Power Of Mind. Boston, MA: Shambala Publications;1996.

3. Khangkar, L. D. Lectures On Tibetan Medicine. Dharamsala, India:Library of Tibetan Works & Archives;1986.

4. Tibetan Medicine (gSo-rig). Dharamsala, India:Library of Tibetan Works & Archives;1980-1989;1-12.

5. Parfionovitch, Y., Dorje, G., Meyer, F. Tibetan Medical Paintings: Illustrations to the Blue Beryl Treatise of Sangye Gyamtso. New York, NY: Harry N. Abrams, Inc.;1992








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