Cultivating Rapport

We will ask questions from general to more intimate. We will need to save more embarrassing or emotional questions for later if we want to maintain good rapport. We want to balance tact and interpersonal flow with medical accuracy. By using a simple and streamlined methodology we can focus on the patient in front of us, timing our breathing to theirs and then slowing ours down and watching their breathing automatically calm down as well. Make sure they are seated and relaxed in their new atmosphere. You want them to feel more at home in your office than they do in their actual home. Some herbal tea is a good place to begin. If your clinic is busy having them wait with a Shangrila Tibetan footsoak is a lovely way to get them settled in. The more relaxed they are, the more they will trust you and give you better information.

Pre-framing Rapport:

To see Jin Zhao, you pay a lot more than to see ordinary doctors. The lines are long and the wait time can be hours. Once you see him he is calm and focused, but doesn’t chit chat. Because his body language is so at peace he can be very direct about getting people to the point so they don’t take up everyone’s time. Because he comes so strongly referred he needs to spend very little time developing rapport. In fact, it’s enough that he is there. His social proof is already strong, that lets people know that he’s powerful, after this looking at them with focus and kindness and laser targeted questions is enough for him to develop strong rapport. After this he asks a handful of very targeted questions.

Anchor questions to chief complaint:

Remember to relate your diagnostic questions back to the chief complaint otherwise you may cause your patient to feel that you are off topic and lack professionalism.

Ask Permission to Ask:

First of all it’s professional to ask permission to ask them questions followed by briefly explaining why you are asking is a great way to get better intel.

It may be obvious to you why you are asking, but they are still trying to determine if they trust you.

Before we begin to use this approach, look for general evidence of dampness.

General signs of damp:

It’s difficult to wake up and get moving even after 6-8 hrs. (Wait thats everybody right?!? No, it is not. That is how prolific dampness is among our target demographic.

Cloudy urination

Chronic pain

Chronic fatigue

Yeast infections (candida)

Brain fog

Dizziness

Weight gain

Heavy limbs

Oily skin

Loose or watery stools

Athletes foot

Toenail fungus

PCOS

Vaginal discharge

Dizziness

Palpitations

Light edema (ankle swelling)


Pulmonary edema,

Hypochordria pain from water accumulation (typically from an enlarged liver),

Sputum and mucus

Tongue:

Puffy possibly with with toothmarks, likely coated.

Tongue biofilm distribution:

Tongue biofilm which covers the base of the tongue may be reflecting dysbiosis in the urogenital microbiome. As the tongue’s biofilm grows to cover the middle of the tongue the more likely it is that the patient has gut dysbiosis in the GI microbiome. When it reaches the tip of the tongue it’s more likely that the respiratory microbiome is experiencing dysbiosis and latent pathogens.

Tongue biofilm color: Yellow tongues are associated with heat. This is not always the case. 72% of yellow tongue biofilms contain bacillus. This has a thermogenic effect on people to warm them up so that the bacillus bacteria can spread out.

Pulse and palpation: Soft, weak, or slippery. Slower pulses tend to indicate “cold” while faster pulses indicate “heat”.

Forearm Palpation: Shi Re: Damp heat. You touch the body/forearm. Feels cool, hold for a bit and it gets very hot. The yang is not spreading.

Movement

As the patient sits down we are going to be watching their movement and face. Is their fluidity as they walk or are they stiff? As they sit down is it easy or is it like they are moving slowly on some type of hydraulic pump? This can give us an idea as to how hindered their muscles and fascia may be due to water retention and resulting muscle fatigue.

The shape of their face and neck.

This gives you insight into water retention and mucus accumulation such as plaque which may add pressure to the heart and create an enlarged neck. You will also want to look for signs of swollen cervical lymph nodes.

The Upper Respiratory Microbiome

“Linda, may I ask you some questions about your medical history? I want to get a sense for how involved your immune system is with this, Do you have any nasal obstruction or allergies?”

If they say yes, then ask, “Do you find your symptoms increasing when you are having allergies?”

Do you have any joint pain associated with changes in the weather?

Does the pain seem to shift from one joint to another? This can be a sign of a generalized immune response.

Adding that last part is key. The fear they have is that you don’t believe in their pain if it’s here today and gone tomorrow. It doesn’t make sense from a mechanical point of view. When they know you are looking for something physical will relax.

Do you tend to feel fatigued with this kind of inflammation?

That last part is important. Fatigue can come with judgements about being lazy or useless. You want to use a good latin word like “inflammation”. To take the sting out of it.

Snoring?

Have you had a sleep study?

Sleep apnea? -Sleep apnea and snoring are signs of dysregulated nitric oxide leading to what is traditonally called “hidden mucus” and it’s also a sign you will add Botanical Biohackings “Warm Hearth tea” (Er Chen Er Zhu)

Now we are entering into more intimate territory. We can use breathing as the transition because of the association of breathing with emotions.

Do you have any constraint in your breathing?

Any wheezing? If yes, it may be a good time to get the stethoscope to listen for lung sounds.

Asthma, slight wheezing in the voice, and shortness of breath can be signs of water retention in the lungs.

Do you get generalized anxiety.

Finally I come to the questions that matter the most.

Do you tend to feel that you need to take a big breath and bear down to start a bowel movement? Do you have obstructed urination? Do you feel that you need to breath into the chest and bear down to urinate? I’m asking this to get a sense for lung function and the actions of the lung on intestinal peristalsis.

Do you feel thirsty or do you have to remind yourself to drink?

Jin Zhao’s three power questions for the respiratory microbiome: 

1.Do you have a dry mouth?

2. Do you feel thirsty?

These are separate ideas in Chinese. A dry mouth with no thrist indicates that the water is there, but not reaching the upper part of the body. This can be a sign of qi deficiency or phlegm blocking the gaseous metabolism (气化) as you see with diabetes. They present with dry mouth and yet are thirsty. No dry mouth with thirst indicates that the gaseous metabolism is occurring but that the metabolism is high and running hot. This suggests that they are getting exercise and if they are sedentary it’s typically a fever which will give them this type of metabolism .It is said that “Flavor arrives via the spleen qi, water arrives to the mouth via the lung qi.”

The sensation of dryness or thirst tells us about the role of the respiratory microbiome on fluid metabolism.

With these two questions and some contextual clues he’s able to get a lot of information.

It isn’t always as easy to use this in the West.

Chinese women tend to drink tea or warm water. They are drinking warm liquid slowly over time. It’s fairly easy to feel that they aren’t that thirsty because they have the social clues that other people are drinking more.

My cultural adaptation of this question is “Do you feel thirsty or do you have to remind yourself to drink.”

This is the answer I get. “I take a water bottle with me everywhere!” They are typically proud of themselves because they read somewhere that they need x liters of water a day.

Then I ask the follow up question, “Do you keep the water bottle to make sure that you are hydrated or do you often find yourself looking for a glass of water, filling it, and draining it?

“Oh no I don’t drain it.”

This is the clue. Athletic and generally active people do look for water and drink a lot of it. That they need a reminder is a clue that their fluid physiolgy has been compromised.

3. Do they need to bear down to have a bowel movement or have obstructed urination?. He is looking for the lungs ability to disseminate and distribute qi to see if the lung function has been obstructed.

If they must remind themselves, then it’s a sign of damp cold. In these cases consider using “Wind Tea” (xiao chai hu and san ren tang”

If they feel true thrist, then it’s a sign of damp heat. Consider using “Peak Tea” (san ren with yin chen hao and chai hu.)

The diagnosis in this case is that there is dysbiosis in the respiratory microbiome interfering with fluid physiology and immune function.

The gaseous movement of the disease state is entering and sinking. To remove this we want to encourage sweating and increase bowel movements to cause the gases to exit and sink. This is like venting the greenhouse and removing the compost pile. This will automatically reduce the temperature.

For signs of cold or a neutral condition we will use Wind Tea. For signs of heat such as thirst or redness in the face or other signs of inflammation we may need to use the cooler variation of this formula called “Peak” which is san ren with yin chen hao and chai hu.

False Heat and Cold Medicine

This lack of sweating also gives a presentation of false heat. Imagine three compost piles piled on top of each other in a small greenhouse. The heat generated from the microorganisms in compost piles can get so hot that it will actually catch fire. As the pile heats up it kills beneficial bacteria that you want in your garden. In order to avoid it causing a fire you would first open the door and windows of the greenhouse to let the heat vent out and then turn it to vent the heat and increase the microbial diversity.

This heat is also generated in the human body. The inflammation causes excess nitric oxide to close the pores instead of allowing them to open as it does when nitric oxide is within a healthy range. This traps the liquid. Imagine adding water to those compost piles. The more water that accumulates will only nourish more bacteria and fungal metabolism. This creates inflammation and heat. These types of people will have a fat tongue, yet the tongue will have no coating. Most common doctors will say, “This is heat” and proceed to give them cold herbs or antibiotics.

This initially works in that reduces some of the bacterial activity, however, it further compromises fluid metabolism which causes even more water to enter, further closes the pores and makes the internal heat even worse.

This happens a lot and people underestimate how cold our demographic is compared to Han dyansty farmers.. They will frequently turn into Shang Han Lun fundamentalists and use ban xia xie xin, for what looks like a combination of cold and heat without realizing the huang lian is too cold for our target demographic who are not Chinese men from 2000 years ago, but rather more sedentary women aged 35-65. Furthermore the true origin of the accumulation it actually cold. It has a time and place, but not as a go to formula for most people in this demographic.

Medicines like this do a little good and a little bad and are why modern tcm doctors have reputations that suffer from mixed results

After asking about the respiratory microbiome you will have checked off some boxes. If they have signs of respiratory microbiome dampness you will think of Wind and Peak tea as your go to formula. Wind is neutral and Peak is mildly cool. If they feel cold, have a feeling that they want to avoid cold weather, snore, or have sleep apnea or just want to feel a bit cozier, then add “Warm Hearth” tea which is er chen tang with cang zhu, huang bai and huo xiang. It will warm, transform mucus, dissolve biofilms, and help induce sweating. This is particularly good for water retention or edema because you will need the added strength this brings.

The Gut Microbiome


Signs:

Fever of unknown origin, Depression, Lack of appetite, loose stools, edema, boryborygymous, gallbladder dysfunction, frothy, scanty, and yellowish urine. Urine that smells like death.


Key questions for the Gut Micobiome

Appetite:

They may lack appetite for vegetables and meat, but still crave sweet and convenient foods. This still counts as a lack of appetite because they prefer to snack on sweets. It’s a sign of pathogenic bacteria hijacking opiate receptor sites in the gut.

Stools:

Stools may be either loose or hard and still stem from damp. When the stools are very small like a sheep’s stools then it is true heat.

Soft, loose, or slightly constipated: Microgard Plus and “Warm Hearth” tea if their face or tongue is puffy or you see signs of mucus or compromised airway passages such as with wheezing or snoring.

“Sheep like stools or sour foul breath: Microgard and Peak tea” as this is a sign of true heat and will require a mildly cooling formula which removes damp without being to drying.

Your go to for anything in this area or for people who eat things they shouldn’t which is most everyone in this demographic is microgard plus. If they have putrid breath and sheep like stool and other true heat signs then microgard regular is better.

You can stack the formulas from the respiratory microbiome right on top of the microgard plus.

Mucus is formed in the gi microbiome and stored in the respiratory micro biome. This is part of the gut-immune axis.

Everything you do with regard to the respiratory micrbome come through the GI as well.

Gut Microbiome Emotions:

Emotionally the GI microbiome has to do with our feelings of love and comfort. This is where the expression “comfort food” comes from. There are profound social meanings with food and understanding ones place and belonging in society. Being fed means being included and it’s very tied to survival.

It is vulnerable to anger and stress which can cause people to stop nourishing themselves or to overeat.

Fear can cause racing thoughts which eat up the body’s atp mentally to the degree that there is not enough to maintain the water pumps and properly devote to digestive function. This is especially true when racing thoughts prevent people from sleeping.

Dreams: People tend to dream of rotten basements or rooms in their houses. They may also dream of home renovation or of eating food. Post apocalyptic dreams or dreams of flooding can point to hidden damp pathologies.

Dysbiosis in the GI microbiome also contributes to emotional depression which is why microgard plus is so important. Jin Zhao frequently combines the concepts of Peak and Wind with Microgard plus and Warm Hearth. This is enough for most cases of dysbiosis in all three microbiomes, but sometimes we need something a little stronger for the urogenital microbiome.

By this time the patient should have no reservations about their body and will be more likely to volunteer information about more vulnerable and sometimes taboo signs.

Urogenital microbiome signs

Inhibited urination, dizziness, history of kidney stones, sweating on the insides of the legs, athletes foot, yeast infections, constipation or loose stools, low libido, toenail fungus, dry skin on the legs especially when seen with toenail fungus, pimples on legs, edema, heavier vaginal discharge. Signs of endocrine or hormone imbalances when accompanied with signs of gut dysbiosis.

Key Questions: Uti, lower body fungi, vaginal discharge

This is where many TCM textbooks say, “Long dan xie gan”. I used to use this as well. You get fast results and the medicine is too strong for this demographic. According to Jin Zhao. “Almost no one in this era should be using Long dan xie gan.”

It’s very rare that someone in this demographic will have signs of dysbiosis in the urogenital microbiome without their also being signs in the GI and respiratory microbiomes. Start with these and then use “Aquada” pills (Er miao wan) as an add on.

This combination is particularly effective when combined with “Warm Hearth” tea (er chen er zhu with huo xiang)

Start with Gut-brain microbiome and add “Aquada” pills if these signs are present.

Menstrual history

light periods, quantity deceased, light color, PCOS, dysmenorrhea which is worse with cold, amenorrhea, infertility, PMS that is worse with poor dietary choices.

Emotionally there is a lot of fear and shame wrapped up in this area. People may dream of rotting basements or underworld demons when they have latent pathogens in the urogenital microbiome or lower region of the body. This can also cause sexual dysfunction and lowered libido.

Prognosis

Every formula we use addresses all three of the main microbiomes, they just have slightly different areas of strength. Because of this there will be increased urination and defecation. This tends to cause looser stools for the first 1-3 days as the body is reorganizing. It can also cause increases in gas. This is a good sign as pathogenic gases must escape in order to bioremediate the body. After this symptoms steadily decrease. The average time to see effect is at the 2 week mark so scheduling patients to return every week or so is a good idea. You are reevaluating to determine what you will adjust between the cooler formulas or the warmer and whether it’s time to switch from an emptying strategy of moving gas out, to a nourishing strategy of moving it in.