The medicine of east Asia is based on a science that does not hold itself separate from the phenomenon that it seeks to understand our medicine did not grow out of Petri dish experimentation, or double blind studies. It arose from observing nature and our part in it east Asian medicine evolves not from the examination of dead structures, but rather from living systems with their complex mutually entangled interactions. Welcome to qiological. I'm Michael max, the host of this podcast that goes in depth on issues, pertinent to practitioners and students of east Asian medicine. Dialogue and discussion have always been elemental to Chinese and other east Asian medicines. Listen into these conversations with experienced practitioners that go deep into how this ancient medicine is alive and unfolding in the modern clinic. People seek out our services because they're looking for some kind of a change. Usually it's because they have something they don't want and they want to get rid of it. Although the opposite is also frequently true. They don't have something and they desire to get it. But something we might not think about is the nature of the change that our patients are seeking or the process of change that they might already be. the two character Chinese word for change can help to clue us in to the kind of change our patients are seeking. I'll be back a little later in the show to discuss how understanding the nature of change can help you with your clinical work Hey friends, before we get into today's conversation, I want to remind you that qiological is coming up to its first anniversary. And for that anniversary show, I'd like to have one of you join me. So if you've been listening to the show and you've been thinking, Hey, I'd like to be on qiological or I've got something that I'd like to discuss, or I've got something that I'd like to share, send me an email or better yet record your voice. Send me the idea that you'd like to talk about. And I'm going to put all of the good ideas into a hat. I'm going to pull one out and have one of you on the. So I'm really looking forward to hearing from you and having one of you join me here on the show. Greg Livingston learned his medicine in China, and about nine years ago, he returned here to the states. He teaches at the Oregon college of Chinese medicine in Portland, Oregon, and he schooled in various aspects of the medicine. And he's turned me on to some interesting books from some docs that I've never heard of. Yeah, just what I need. More books, you know, different people sort of develop an eye for different aspects of the practice, or they've got a knack for a particular illness or condition for Greg that would be blood status, which is something we often talk about. But Dr. Livingston here, he's like a blood status whisper. I'm looking forward to this conversation about a topic that we all deal with every day in our clinical practices. Gregg, welcome to GLI.

Thanks, Michael. Thanks for having me,

you know, it's so geeky getting together and talking about something like blood status.

Yeah. But you know, that's what we do. We geek out, you know, TCM geeks let's face

this good Lord. What were your influences? Where there teachers were their books? Was there something in clinic? What got you going down the rabbit hole of blood

stasis? It's certainly not the only thing that I concern myself with in Chinese medicine. But over time, I started to see that a lot of patients have blood stagnation and some teacher of mine said that health in Chinese medicine can be defined as high quality blood, nutritious blood, highly oxygenated, blood circulating, completely unimpeded throughout the. That's the definition of health, not physical fitness health is unimpeded blood flow. You have really high quality blood, highly oxygenated circulating unimpeded, and then all the tissues will function well. And that's not a new idea, certainly, you know, in Chinese medicine, the idea like futons it's all right. If there's obstruction there's then you on a block it, then the pain goes away. So Chinese medicine is all about circulation of chia and blood. I mean, not all about that, but it's so fundamental. I often forget about it. Yeah. But it's just one of those basic things that you need to be concerned about and people end up. Impaired blood circulation for a variety of reasons, right? We can go back to, you know, the signing, the three categories of disease causing factors, right? Nene, why enable what the internal, external and miscellaneous causes of disease, either internal or external, either internal or external. So any of those things can ultimately cause blood stagnation, right? External pathogen, invades, and impairs circulation of GM blood and internal factors, the emotions, impairs circulation of GM blood and the miscellaneous things, trauma, uh, animal bites, those things, surgeries, they, those things end up impairing circulation of GM blood. So especially with chronic patients and older people, you see less with little kids, but even you can, but certainly people once they're middle age or, or elderly. They usually have a lot of blood stagnation. And so I've found that it's one of those things that if you know how to identify it and you know how to treat it, then the results are pretty miraculous. And I'm known for this at OCOM where I teach as being a little bit obsessed with blood stagnation, actually all the students that follow me in the clinic, they, they know that that it's a thing of mine. I don't think really that it's me being obsessed with it. It's just everywhere. Right. I think it's, it's everywhere. And I think it looks like I'm obsessed with it because a lot of people don't know how to see it and they don't know how to diagnose it. They don't know how to treat it.

So what does blood stagnation look like? And more to the point, maybe what is it that your average practitioner like me might be overlooking sometimes in clinic? There's these weird signs and symptoms. I don't know what that is. And you kind of just put it off to the side, hoping it will later fall into the pattern, but it never does.

Yeah. I mean, it could be something like that, but a lot of times this stuff that's just staring you right in the face, but there are things that a lot of practitioners, I would say largely in the west, I didn't meet too many doctors in China that had trouble diagnosing that. But in the west, you know, I think generally people's diagnostic skill is not quite as good as in China. So there is exceptions obviously, but so what are we looking

at then? What would, what would help us to make sure we're not missing

the obvious? Yeah. Well, the first thing I would say is the complexion that you can see it. When people walk in the room, if it's significant, they have an ashen complexion. There's no sheen. You have to understand that the blood vessels that feed the skin. Our tiny little capillaries. And so it's easy to occlude those vessels. If this blood circulation is sluggish systemically, then almost sure the blood circulation to the skin will be impaired. So the skin is dry. Lacking sheen becomes ashen colored. Also in Chinese, we call jots hall jots who has that scaly looking skin. It's dry and looks kind of scaly, especially if you, if you take your fingers and you sort of squeeze the pinch, the skin together a little bit, it'll look a little bit rough and scaly. And then the other thing which a lot of people don't realize, for some reason that's not well known, or at least in my experience here. And the in the west is pigment spots, pigment spots as a huge sign of blood stagnation. I mean, like, exactly. Those are blood

stagnates. So for you listeners, we actually have a video as we're talking to each other, but I'm showing the back of my left hand.

Yeah. Yeah. So that's, that's clear sign of blood stagnation. Some people have freckles, that's not blood signage, but if they're what we call eight spots, that's blood stagnation. Why do people get that as the age? Because as people age, they tend to develop more and more blood stagnation. Do you know this? Dr. Yen does sheen, which is a very famous law. It's only not familiar with him. He's kind of the, the number one big guy in shy. What's his name? Yeah. And does sheen, Y a N D E X I N. Yeah. Okay. We'll put

his name on the show

notes that he's very famous for his discussions of blood stagnation. He's also kind of obsessed if we can say that with blood stagnation. So I read a lot of his stuff actually, that he definitely had a bit of an influence on me. So Yenta sheens says that one of the main causes of aging aside from decline of essence is blood stagnation. So yeah, as people age, they incur more blood stagnation and they get those age spots. So you can see those anywhere on the body. It's very easy to see them on the hand. And since we're checking people's pulses, hopefully then, you know, you can have a look at people's hand and arm. You'll see pigment spots there. Purple lips is another thing that you'll see of course purple. And then one thing that I particularly like to inspect is the lower leg. Aha.

What are you and what are you looking

farther? The lower leg, the blood circulation is particularly difficult. It's far from the heart. And so circulation in the lower leg is particularly challenging. Blood stagnation signs will show up on the skin there very readily. So you'll see discoloration purple, blue, green color varicose veins. And then of course you get to see that dry, rough, scaly skin. Dr. Wong

talks about that a lot. Yeah, he does. He's he's real big on that.

On that lower leg, he loves to inspect the lower leg. That's right. Also Hong Kong showed me, I think it was Hong Kong showed this to me, but it's been a long time. So I can't remember exactly where I learned this, but a thickened here. Thickened skin on the heel is another sign of blood stagnation. Obviously you can't just automatically say, oh, that's, you know, 100% blood stagnation, but if the lower leg you can see discoloration, dry, rough, scaly skin pigment spots. And the heel is thickened even to the extent sometimes where cracks that's blood stagnation. So those things are the, uh, you know, it's part of the visual inspection. And you'll see that on a lot of people. It's, it's quite remarkable how many people have those signs and symptoms. And

I suspect, especially as we get clued into it or clued into it again, it's like, oh yeah, there it is. And there isn't. Oh yeah,

there it is. Yeah. Like for example, I had a patient, this is a very. Memorable patient. Cause it was such a, it was a pretty serious case of a patient with very severe PTSD is a woman in her, I think maybe early sixties from central America. And she had been, I think she was from El Salvador. So she'd lived through the war there and her son was killed. Her son had been killed. So after that she had night terrors, uh, insomnia, anxiety, depression, fatigue, cause obviously not sleeping, eventually develop hypertension. So she was on hypertensive medications, Xanax, I think antidepressants off and on over the years. And this is, you know, decades long problem she'd had for. Easily like 20, 30 years and no one had been able to help her. And I saw her at the OCOM clinic. So oftentimes patients at the ACOM clinic, they've seen multiple practitioners, including other faculty, not just interns, but they've seen other faculty. And I look at the prescriptions that other doctors had given her. And a lot of them were calms and prescription, right? Like maybe swans are on Tom or or or for the high blood pressure. People's thinking can be that simplistic sometimes. They'll you have high blood pressure, just take TMR, go go-time, which that's a whole another conversation. Why that's not a good approach. But anyway, this patient walked in. The first thing that came to my mind, just looking at her face was, I don't know what's wrong with her, what her complaint is, but whatever it is, she's got a ton of blood stagnation because their face is very ashen. Her lips are purple. She's got pigment spots on her face. So I'm like, whatever her problem is, for sure. There's a ton of blood stagnation there. So then we got to talking to her and it took me all of about a minute to decide on the formula. But you know, it's an intern clinic. So, you know, we spent the next hour letting the interns do their intake and trying to sort out and figure out which formula to use. But she had chest discomfort, even some like a little prickly sensation sometimes in the chest. And should we get cold extremities when she's stressed? So automatically I'm just thinking shrift. If you read Ealing guides, whore, right? The one children's book where comes from, I'm not sure how to translate the title of the, that book's been translated into English. I think it's something like correcting the errors in the forest of medicine. I think that's how they translate that. I think that's yeah, but anyway, sure. If we'll do Taiyang and all those two tongues come from launching, and from that book, if you look at the entry for shifts where you're talking in that book, I think there's about 16 or 17 different indications. And about half of them are mental, emotional, including night terrors, yelling in your sleep, insomnia, nightmares, that kind of stuff. You know, wanting to identify blood stagnation as a cause. And in particular heart blood stagnation as the cause of these kinds of mental, emotional disorder. So automatically I just think sheriff. And so we did that. We gave her a shuffled futon. We didn't modify the doll. We didn't add swans out and we didn't add Longo Muhly,

you know, it's, it's great to take these formulas and use them straight up, just watch what they do without getting in there and fidgeting. I mean, sometimes

we need to, you know, because I teach, I just feel like a little bit of a broken record, cause I'm always saying the same thing over and over that ultimately it's all just been, so just pattern, differentiate and try to understand the pathol mechanism. Right. In Chinese. We often talk about being in being GI, being in, being etiology, being G patholo mechanism. So my teachers talked about being, being G all the time and I don't hear that or read that too much in English, but it's really imperative to understand Pathwell mechanisms. So it's like, okay, if, if someone has blood stagnation in the chest, First of all, how could it have gotten there? Well, this person went through some severe emotional trauma. That's going to constrain the chief at the very least constrained the liver chain, right? And then the liver channel goes to the chest. So that liver cheese stagnation, one of the Cardinal signs of liturgy stagnation, which also people forget is chest tightness. People remember subcostal discomfort, flank pain, but chest tightness, chest discomfort is another important symptom of, or sign of liver GI stagnation. So Luci stagnation constraints, the chief and the chest in Paris, heart, blood circulation, and then long term, especially with severe emotional stress like that kind of PTSD event that will make heart blood stagnation. Then the heart is not nourished because the blood circulation in the heart is impaired. I mean, literally the circulation in the heart is impaired. It's not metaphysics. It's literally the circulation in the physical heart is impaired and you can feel that on the pulse too. And those that patient actually had chest pain, little sharp, prickly, chest pain. It is the coronary arteries. There's some impaired circulation. It might be in the small vessels, but anyway, there's definitely impaired blood circulation there. So then if the heart blood circulation is impaired, then the ShaoYin is not nourished. Then you end up with all this different kinds of mental, emotional problem. So in that case, all you need to do is deal with this CIM blood stagnation. You don't swansong and doesn't address that pathology at all. Neither does So it's all about proper differentiation pattern differentiation, and then understanding the patho mechanism and the etiology, if you can. And then it's very clear, like that's a shift, we'll do your tongue pattern. There's no need to add any other herbs to that form. And so we gave her a shrift with zutang and immediately within, I think even the first night after she took that she could sleep. It was just, it was remarkable. And, uh, I mean, we dosed it pretty high too. You can't take some small dose of it and expect those kinds of results. What do you call a high dose of it? I'm pretty sure we gave her bulk herbs. Uh, cause I I'm pretty adamant about that in situations where the it's a kind of a severe case. Yeah. Like childhood, probably 15 Michelle 30, just should of 15 guns house, six to nine. I can't remember what we gave her maybe because she's hypertensive. We gave her six Tara and 15 home law, nine Sunday. But like a bag of day like that, I'm going to come back to

this in a moment, but I want to veer off to the, to the side here, this, this, this may be getting into troubled waters, but yeah. So what you were talking about, how your experience learning in China, there was a big emphasis on really knowing the path of mechanism. What are we actually looking at here? What's going on? You're saying we don't get that so much here in the United States.

Well, that's my experience talking with Chinese medicine practitioners here. What's your

stance. How come we don't go into that? Is that not in our education? Is it, do we think differently? What's

I think it's just not in the edge. It's not emphasized in school as much. And trying to it's a big thing is that everyone knows you need to understand being in being G is they, they emphasize on that, but here. I met a lot of people, even people who've been in practice for some time that sure. They probably had heard those terms before, but they weren't obsessed with it. I'm obsessed with that. That's, that's something you need to be obsessed with. In my opinion, you need to not just be differentiating patterns you need in order to be good at pattern differentiation, you have to understand etiology and patholo mechanism because that's how you arrive at good pattern. Differentiation. You have to understand what's the mechanism behind this person's signs and symptoms. So for example, the case of blood stagnation, why do you get rough, dry, scaly skin pigment spots? Well, the blood circulation is impaired. The blood circulation to the skin is particularly difficult because it's all capillary circulation capillaries. If the blood circulations systemically slugging. Then certainly capillary circulation is going to feel it the most, your aorta. There's still going to be plenty of blood flowing through aorta. Otherwise you're, you're dead. Your capillary blood flow can be, you know, somewhat impaired and you still get around. You might, you might feel a little tired we'll sluggish, but you still survive. So what is it that makes the skin look like that? Right? That's Pathwell mechanism. So the blood circulation there is difficult. The skin doesn't get enough blood and nutrients, so it becomes dry and rough. And then how does the pigment accumulate there? Well, when people are exposed to sun, pigment is deposited in the skin and then when they're not, then the blood comes around and metabolizes those pigments and takes them away. And that's why a 10, especially if you're me, cause I'm pretty pale. It doesn't last, very long. Right. You get 10 and then it goes away because your body came around and metallic, literally the blood came around and metabolize those pigments and took them away. If you have blood stagnation, the pigments are deposited, but they never leave. So then you end up with pigment spots, that kind of analysis. That's pathol mechanism. It's important to do that across the board when you're seeing patients, it's not so

much a thing of going, oh, this patient looks like they fit in this box. It's more, oh, here's what I'm seeing. Oh yeah. It's this.

How do we explain all these signs and symptoms? It's not enough to just say, oh, to memorize. You know, for example, a lot of people have this impression that night's sweat is from individually. I think if you ask a lot of people, what's the cause of night's sweat. They can only come up with that. One thing they think in deficiency causes nights. Well, I, you know, it's one of those things,

that's the first thing you learn. It's almost like a native tongue, right? Your native tongue is easiest. You can speak other tongues if you learn them. But it's like, there's a certain default. I mean, when I think of like cheats efficiency kinds of things, the first formula that comes to mind is Why is the first formula learn for cheetah efficiency? It's like, there's these things, these various aspects about the medicine that we learn. And it's like the first time we hang an idea on it, but there was all these other possibilities, you know, we have to keep looking at all the other possibilities.

Right. If you think patho mechanism all the time, analyzing the signs and symptoms, not just memorize a pattern. For example, we can talk about chia deficiency. So chia deficiency pattern. Well, let's just talk about sweating from G deficiency. That's an interesting thing, right? Cheat deficiency people. There's not enough cheat to regulate the opening and closing of the poorest, right? So typically upon exertion, when you're consuming your key, then you have a little less cheap after exertion. Then there's less cheat to regulate the poorest of the poor slack open. And the sweat comes out. That's understanding the path on mechanism of deficiencies sweating. If all you know is that cheat efficiency, people sweat upon exertion, but you can't explain why that's not enough. You need to ask why for all these things, the why is the path home mechanism? So that's in my mind and all my teachers' minds. And I think in most Chinese medicine doctors in China, they understand the importance of not just memorizing patterns, but understanding the mechanism behind all these signs and symptoms. And if you, if you practice that way, if you think that way, then over time, it actually becomes pretty simple. You start to understand, and you can, you can really unravel a lot of difficult cases that other people weren't able to treat because somehow the presentation of the patient didn't match any recognizable pattern that they have memorized. They don't understand how to think about Pathwell mechanism in a sophisticated way. So then they fail and their diagnosis, their diagnosis comes up short like this patient. We were just talking about this PTSD page. People see insomnia or hypertension, right? The patient has hypertension. So I think someone had given the patient Tambo go and they see insomnia. So they use done. That's not thinking about patho mechanism, that's just link a particular sign or symptom to a particular pattern.

Well, and then you wouldn't know what to do when something like Swan sour N would maybe make that situation

worse. Exactly. Actually swans around town could make this patient worse. I mean, as far as the runtime, at least it has So that's, you know, maybe not the worst thing you could do for the patient, but like for example, you give that patient tell on bougie and dad you'll definitely make them worse. All those cold sticky herbs, it's going to gum up her blood circulation even more and TMO goats hanging. Yeah. People love that for hypertension, but not all hypertension is liver young, rising. Some of it is, but a lot of hypertension actually is due to blood stagnation. After she took the strip. At two time, her blood pressure actually started to come down. Her blood pressure came down, she came off some of those blood pressure meds and some of the psych meds. And yeah, she was sleeping through the night. I mean, it's still, she had some issues, but, uh, she was much, much better even after. And I don't think we just gave her shrift futon. That was the first formal. And then over time, the formulas changed a little bit, but definitely blood stagnation was part of her treatment. I think for almost the entire time, because one of the things about blood stagnation is very stubborn stuff. It's often takes a long time to address it, but anyway, she was taking this blood stagnation nurse for a long time and her complexion improved too. She was really happy about that formula. It is a beauty formula. Her skin started, it was more moist and had more shine. And the pigment spots start to lighten a little bit. She looked less ashen and more like Rosie cheat like that. So she was very happy. Not only she felt better, but she looked better. So that was a very, very nice case. It's a very instructive case. Yeah.

Yeah. So I think most of us are familiar with that. There's a deep, deep connection between the ShaoYin and the blood these days. I don't know what your practice looks like, but I would say at least a third and at certain points up to half or so of my patients are in some kind of, you know, Xanax or Lexapro is the big one over here. And in the Midwest pack, fill, you know, all these, these kinds of mood meds. What's your experience with these kinds of psycho emotive issue is where people have been given these medications that really in many ways, keep them away from their emotions. How do you see that playing in with blood

spaces? It would be wrong to say that all those people have blood stagnation. I mean, maybe they do to some extent or another, it would be wrong to say that all those people's mental, emotional problems, you could just simply chalk up to blood stagnation. I think it's often at least part of the pattern. It may not be the only thing. I mean, that's the other thing to remember is that people's problems are often, there's many things going on. The blood stagnation is part of it, but there can be underlying deficiencies and there's HEA there can be cold, right? There's all different things going on and you just sort of have to peel the layers. But blood stagnation is often one of those layers. It's often one of the overlooked layer. I would say that a lot of those people, I do end up treating them for blood stagnation. Again, not because I think the blood stagnation is their only problem, but they do have that they, those people often have, you know, they have emotional problems. So they have chief stagnation. She stagnation leads to blood stagnation and, and, uh, so ultimately you do end up putting in some herbs for blood stagnation, put some dance and in there, or, you know, you can use a shift for two Taiyang or of course you need to figure out where the blood stagnation is and go after it. For example, if you read song Hyla and D downtown downtown is FOC harm, right? Quality craziness, right? Mania, craziness. So D downtown is blood stagnation in the lower abdomen, right? Lower back. right for the lower burner blood stagnation. It's not just heart blood stagnation that can make people have some mental, emotional problems. It could be blood stagnation anywhere. So you don't have to try to figure out where their blood stagnation is. You can palpate the abdomen. You can of course, try to feel it on the poles or look on the tongue or facial diagnosis, all those things you just go back to Benza on, you know, and, uh, to basics in some ways back to it's really back to basics. I think for me, one of the key mistakes I see students make is they focus on chief complaint. That's for me is a big mistake. Chief complaint is only important in that. Okay. That's what the patient came in to see you for. That's what they want you to fit. You know, you're working for them there. They hired you. So you should fix the thing that they want to have fixed, but how you fix it, that's, that's your job, right? If you decide, okay, this patient has, we can go back to this PTSD patient. Right? Okay. They, they, they have PTSD. They want to sleep through the night. They don't want to have night terrors anymore. So that you're obliged to treat that how you do it. Like if you decide, you need to treat that person, say, say, you believe their problem is because of their digestion there. They don't want you to treat their digestion, but to say, it's their digestion causing the problem. Well, then you explained to the patient from a Chinese medicine perspective, I believe your problem is coming from the digestion or whatever it is. And in order to get at this problem, we need to work on this. I will

often use a kind of a metaphor to try to get them to understand that. So for example, I have certain patients, they come in and they, they, you know, ask them about their sleep. They're like, well, you know, I'm up several times a night, you get a little deeper into it while they sleep kind of lightly. And their spouse snores like a freight train. Oh, you know, maybe if the spouse snored less, you would sleep better. And in some cases that's actually the solution. Yeah.

Yeah. It can be, but students, I see, I find, and again, you know, I, I guess, cause I'm teaching, I maybe my impression of Chinese medicine in the west, it's not even fair to say maybe it's, it must be skewed because I'm just around students all the time. Right. So they're, they're, they're newbies, right. They tend to see chief complaint and then they, they try to match the chief complaint to some pattern. But it's important. I think to step back and re remember the chief complaint. Is not more important than any other sign or symptom. Yeah. It's the thing that the patient wants you to treat, but it doesn't carry any more weight in your diagnosis then any other sign or symptom. So step back and look at the big picture, try to figure out, you know, what is this person's overall pattern? And, you know, you've got to focus on, on that. So, you know, the bowel movement and the urination, temperature, sweat, those things are as important to understand as their, you know, their chief complaint, all those things carry equal weight. Well, it helps us

understand

their chief complaint. That's exactly right. So that's what gets you to the diagnosis? Not like, oh, they have hypertension. Therefore that must be liver. Young, rising hypertension is just one sign, right. That you can use. So you need to look at all those different. Again, just from what we talked about, the very beginning of this conversation, blood stagnation, I feel it's not something that I'm obsessed with. I think it's just something that other people overlook and therefore it makes me look like I'm obsessed because I can identify it very easily. And I just see it in a lot of people. That doesn't mean that I'm obsessed with it. It just means I'm good at identifying it. And maybe other people are not time for

a little break here. I don't want to share with you some brilliance that I gleaned from Sabine. Wilms' new book humming with elephants. It's chapter five from the PSU end. And it's about the resonant manifestations, a yin and yang in the book. She points out that while in modern Chinese, the two characters BNY mean change in a sort of generic way. Each of the characters separately. Speaks to a different kind of change. Again is more of a step-by-step incremental change. Whereas Y is a transformation that profoundly and irreversibly changes something. So for example, a rainstorm would be a BN type change while the typhoon that blows your house down. That's why slowly Stephanie arthritic joints that's BN I cancer diagnosis. Well, now you're looking at why it's helpful to keep these distinctions in mind as your patients might be in the midst of a hot type change, but they were really hoping for a more of a PN. Likewise, they might not want to step-by-step incremental nature of a BNY type change when the transformative Hua is what they're after. So the next time a patient comes in looking for I'm using quotes here, change. See if you can differentiate what kind they're looking for. Is it PN or is it. You know, I created qiological as I think the practice of medicine requires us to constantly study and change our perspectives. I've created a Patrion page, so you can contribute to this endeavor by becoming a contributing subscriber. In addition to feeling the satisfaction of knowing that you're helping to support a podcast that you love. There are a few special goodies available for contributing subscribers to the podcast. For those details, head over to qiological.com and click on the Patrion page button to help keep a little inspiration in the. Thanks for your consideration. And now let's get into the second half of this show. So, I mean, we talked about pigment on the skin that, you know, what's, the skin looks like the dryness, the luster, of course we have tongue and pulse, that kind of thing. I mean, have you got any other kinds of, uh, secret blood stagnation signs or, or things that maybe we'd over, some people might overlook that you just, you just know how to tune into it's like, oh yeah, that's blood stasis.

None of this stuff is secret. I think it's just stuff that maybe people haven't learned or they forgot or something. But like I said, the first thing is a visual inspection because often that will give it away, but then the pulse, but post-diagnosis is of course a little trickier. But I think ultimately when you're thinking about pulse and actually everything in Chinese medicine, even everything in the universe, we can boil down to either. Everything boils down to India and same with the pulse. So when you think about the pulse, if the pulse is eating and what is the impulse? Well, deep is Ian versus floating as a young, thin pulses in wide pulses. Young rabbit poles is young, slow pulse is in like that. We just think about the pulse, just break it down to young like that. And if you think about it, any, any of us can do that. Anyone who's studied Chinese medicine, it's super simple. Right? So then you think about, okay, if you have an EAN Paul's well, then there's IIN phenomena in the body. And if you have a young pulse, there's some young phenomenon occurring in the body. Right. Okay. Then what is blood stagnation? Well, blood belongs to IIN. Blood stagnation is dead blood. So that must be even more in than regular blood. Yeah. Let's stay nation is, is impacting. Just like phlegm. Damp is also Ian pathogen, right? Let's stagnation is in pathogen. So it makes the post in. It makes the pulse deep. It makes the pulse thin, but blood stagnation is an excess. Excess is young deficiencies, right? So let's stagnation poles is often thin and deep, but forceful because it's, Yangming the main thing to differentiate excess and deficiency on the pulse is strength. That's the main thing. You can have a thin pulse, thin POLST and wide polls do not represent excess and deficiency. I think people forget that they think, oh, thin that must be more on the deficiency side. Why that must be more on the excess side, but remember Shuma deficiency Paul's the actual deficiency poles is floating and wide. You could even have

a deep, thin,

tight pulse. Yeah, deep, thin and forceful deep, thin type. Also typically like excess cold. So deep thin with a little bit of force and it is typical blood stagnation pulse. So for example, the left one, because liver stores the blood, we often can feel blood stagnation in the left glide, right? Liver blood stagnation will typically show up as a deep thin, but forceful pulse. Remember when there's stagnation, you often get heat from constraint. That's another thing I'm, it's probably fair to say that I'm obsessed with this constraint, heat constraint, heat,

heat, secondary to constraint.

Yeah. That's a big deal. And I think most people don't really understand that very well, that they don't understand how to treat it very well because it's different. Treating heat from constraint is different than treating some other types of heat.

Can you give us an example of that one? It's a great example. I think it's something that we. Run into, on a regular basis. It's why is prescribed by so many practitioners,

well, heat from constraint. There's a thing in Chinese as a whole, you thought, well, if you had to means fire constrained, then disperse it. So constrained heat, you need to disperse. You don't use cold, bitter, downward, draining cold and bitter things. They have an inward movement. They cause constraint. Actually, they tend to actually cause contraction in the body. So whole you fads a means for fall is a young treatment method, accurate warm herbs, young type herbs to disperse constraint. When you disperse the constraint, then the heat naturally goes away. Now, the reason has in it is you want to mop there's heat there. So you need to mop up the. It's not like there's no heat. So you don't, you can't put any, you can only use warm disbursing herbs. No, you use moving herbs on the accurate side. Some of them can be warm. That's fine. They're generally not hot herbs, but sometimes they are. But then you put a little bit of some cold herbs in there that mop up the heat because you do need to mop up the heat, but it's not a predominance of cold herbs when there's constrained heat. Otherwise you will get rid of the heat because you're using cold herbs. The heat will go away, but you're going to make more stagnation. And then ultimately there will be more heat. When the person stops taking the medication, then the heat is going to come back with a vengeance and you'll make more stagnation. You're actually going to you. You can actually plant the seed of someone's tumor doing that. You know, if Chinese medicine can dissolve tumors, if seen it, you can dissolve people's tumors. You don't think you can make people's tumors. Oh yeah. You absolutely. Can't you may not realize it. The patient may not realize it because it's happens 10, 20, 30 years later, but you can very easily plant the seed of someone's malignant tumor by wrong treatment. The patient will never come back and say, oh, Greg gave me this, you know, tumor. They'll never connect those two things together. And most doctors also won't connect it and you can't 100% connect those things anyway. Right. There's too many variables you can't say, oh yeah, this mistaken formula causes person's tumor, but you absolutely could. So that's, that's another huge topic, heat from constraint and how to treat that. But, well, and also it just

gets into the thing of how we know that we're doing no harm.

Oh yeah. That's, that's a tricky one. It

is a tricky one because people are looking for help. We're looking to help with the best that we know.

You know, when I look back at some of the stuff I did early on in my practice, it's far from ideal. Yeah. I, I do not envy the patients that I treated when I was, uh, you know, younger practitioners, uh, definitely made a lot of mistakes. I still make mistakes, but just less and less, the mistakes are less, less severe. Now that mistakes are inevitable. I emphasize this to my students all the time. It's like, if you think you're good, think that you're right. Most of the time you need to take a step back and, and have a look at yourself because it's very easy to be wrong. It's actually very difficult to be. Right. Right. Diagnosis is really difficult to be wrong. It's super easy. The odds are completely stacked against you being right. So always be second guessing yourself, always realize you can do better. Even you get good results with a patient, you almost sure could have done better.

How

long have you been practicing now?

How long have you been here? 20 years. A little over 20 years. And then, you know, in China saw a lot of patients. That's, that's the main thing is this. I got to see it because I was licensed in China and I practiced there as well as followed my teachers. So I saw thousands of patients and then I followed a lot of good teachers. So they, I didn't make any of this up. You know, I don't take credit for any, anything that I know or do in Chinese medicine. I didn't make any of it up. I just learned what other people do and copied them. Well, this is, this

is how we learn. Right. And then at some point something comes through that. That probably is ours

maybe, but, but it's,

it's

a process of refinement.

Yeah. I don't really consider that. I made anything up. I just, you know, even like the formulas, I tend to not make up my own formulas. I tend to use old formulas. And I mean, I, I kind of default towards the Jean falling approach, the classical formula approach John's own gene because I find that super effective, but I'm not dogmatic at all. Or, you know, I'm, I'm kind of eclectic. So I'll use launching runs formulas and I'll use John J beans formulas and I'll use yeah. Modern stuff. all that stuff. I'd use anything. I learned a bunch of stuff reading. Yeah. Does Shane's book, right? Like I learned how to use bugs, a lot of bugs actually, by reading about. His stuff like how do you, how to use bugs is a big

thing

for blood Stacey's that's a huge one. All right. In a moment,

I want to come back and talk to you about clinical mistakes. Cause there's some gold to mine in that. And I just have some personal questions. So we're going to come back to that, but first.

Oh yeah. Well, there's a thing in Chinese SRE, yo yo Ching shadow shadow means literally means blood and flesh, blood and meat. That means animal products Yotes seeing means has an affinity. Literally blood and flesh has an affinity. So animal products have an affinity for the body. Animal products have an affinity for the human body because it's closer to us than plant and mineral.

So that's why we eat meat to tonify.

That's one of the reasons I would say, but from an herbal perspective, what, what does that mean should reel your chin? It means that the animal products they're eating, first of all, they're easily assimilated by the body. That's the first thing. And the second thing is they go deep into the body. They go into the deep space where those plants and mineral substances can't easily get. Yeah. 10 should have talked about this, a fair amount about the law. My right. Here's the thing. Joel being drew law, Joe being law means all disease goes to the law, the law am I being the small vessels and what we're talking about, blood circulation and blood stagnation and blood stagnation tending to be a chronic problem, a GL being an old disease, it ends up in the law. Let's stand nation ends up going and settling in the loop. That's one of the reasons that it's so stubborn,

it's in the law. It's these tiny little vessels. Yeah. And sometimes there's Fleming there as well. That makes it even more interesting.

Absolutely. Cause blood stagnation and phlegm. There's another thing we say, Todd, you told you that TaiYin is flat. You blood stagnation, tome, you and means same origin, which just means not that not necessarily that they come from the same place, but that they're, they're related to each other. They transform into each other. When there's blood stagnation, there's almost always stagnant fluids. And when the fluids stagnate, there's almost always stagnant blood. So because of that, blood stagnation becomes really stubborn problem. Very hard to get rid of, even to the point where you're not going to be able to get rid of it and all the patients, that's why people are more. If, if, you know, if Chinese medicine could cure all these things, right. Get rid of all blood stagnation, you could, tonify the kidney endlessly, then you're immortal, but clearly that's not happening. Or at least I'd haven't met any immortals yet. So that I know of. So you can't get rid of all the blood stagnation, but you can get rid of some of it. You can extend people's life by getting rid of their blood stagnation by tonifying their kidney and all that. And you can help with their PTSD. Yeah. Improve their quality of life. And it literally, you can extend longevity, but proper Chinese medicine treatment. That's sure

there's a friend. I have some conversations with in Taiwan and he's into various Dallas practices and martial arts and, and, and we've had some discussions around what it means to be a mortal from the Chinese philosophical and talus perspectives and all that. He has a really interesting take. His take is not that you live for. His take is that you completely and fully live your lotta days. And if we can do things that help people to live their fully allotted days, that's an aspect of being immortal, right? I mean, if they're not able to completely live their full days, like this woman with PTSD, right? You take some of that away. They, they get to live more fully. I suspect this is why there are some herbs and you know, there you eat a bunch of this. You become a mortal it's, it's not that you live forever. It's that you live more fully and better what you have.

Yeah. Well, we're definitely capable of helping people with that. Chinese medicines well suited. It's amazing how, how good it is at accomplishing that. So

let's finish up with the bugs here and then I want to get into mistakes.

So anyway, the bugs go to the. That's the thing. They Ching idea that they have an affinity for the body. They go deep into the body. They go to the law of Maya. So they're used typically as guiding herbs, you don't necessarily need huge doses of them. People are scared to use those things because when you read about them in the book, they're usually they push yeah. They break the blood and they, it makes it sound like they're the strongest blood moving herbs out there. And they're dangerous. They're going to make you bleed. It's like taking warfarin or something like that. It's absolutely not the case. They're not actually stronger than other herbs. They just go deeper and work on that old stubborn blood stagnation, actually sun lung hoods. As an example, I would say are more damaging to the blood, which is stronger to move the blood than a lot of the bugs. That lot more than leach, more than to be at home. More than D long, which those are kind of the big, well, amongst home, of course, which is hard to get anyway. But, uh, I think most people are kind of scared to use, switch, right? The leech and to be at song the cockroach probably cause they're, they're, they're, they're stinky and they're kind of gross, but

patients freak out when they see bugs in their

formula, they do, but you can explain to them. And I mean, my patients, they're fine with it. Most of them, I rarely had anybody object to that. Um, I'm going to have had some, but mostly not. But anyway, again, it's not that they're so strong. It's just that they go to the law, my, and they get at the old blood stagnation and you don't even need to dose them high. You, you use them as guiding herbs to help direct the formula and bring the other parts of the formula to that space in the body where that old blood stagnation is hanging. And so you use them that way. Like is a perfect example of that, which is the formula. Most people don't know of. Docklands is Hawaiian and Dawn's is Hawaiian is from Jinga Yala. And it's from interestingly, actually very interestingly is from the Shula chapter of Shula was the deficiency taxation, right. That's extreme. And in fact, if you read the line for Docklands is Hawaiian it's, um, Shula, G law G Lao means extreme taxation. And then it gives a bunch of signs and symptoms for that, which include like jot the rough, scaly skin and a dark circles around the eyes is one of the symptoms. But anyway, it's extreme deficiency, taxation where this person overdid, it made their body extremely weak. And now they have this old blood stagnation. And when you look at the formula, it's got, of course Dajuan, cause it's called it's all one. So this home is to be at home. It's got swayed, drew the leech tall, Jen it's, it's like a, it looks like a really heavy blood stagnation formula. Like you you'd be scared to give that to people if you're, if you're scared of blood stagnation, herbs to begin with. I think a lot of people are. So when you look at that farmer, they're like, oh my God, that's that formula. Is so strong, where are you going to find a place to use it? And then the place to use it is in some person who's incredibly weak and debilitated deficient at first glance, it doesn't make a lot of sense. But then when you think about it, what's happened, there is this patient for whatever reason has developed old and very stubborn blood stagnation throughout their body. That's impairing obviously circulation of normal, healthy ch he blood and body fluids. And then all the tissues become malnourished. And they can't recover from this situation because their circulation is so poor that their organ function and all their tissue function just starts to decline. And so that kind of patient, you can't tonify them cause they can't accept tonification

right. In fact, if you give them tonics, you'll make it work. You only increase the stagnation

right there. You absolutely make it worse. So then the F the formula is Don's, it's a line which very notably important to note is it's a wine, it's a pill, it's a honey pill. So those herbs are ground into powder, mixed with honey and taken that a fairly light dose. The honey moderates, the harsh nature of the herbs, and it's taken out a small dose. So you just little by little whittle away at that old blood stagnation. And then you can bring the new blood to the tissues. And then the, the tissue organ function starts to recover. And then at a certain point, when, once you've resolved some of that stubborn stagnation, you could start to add some tonic herbs to a patient like that, but that's really instructive. You know, that that shows you that those herbs they're not damaging the body unless you use them inappropriately. Of course, like if someone has a lot of blood stagnation, you might think, and they're really debilitated like that, you might think, oh, moving the blood more is going to damage the blood more damage the body more. But those people there's, you can't do anything until you get their blood moving. Right. So we're

really back here to something we talked about earlier in the show, really main point of yours, which is understand the path home mechanism. When you understand what you're looking at, it makes it a lot easier to go, oh yeah. This formula here. And here's why it works.

Yeah. Absolutely. Patho mechanism is the key in my mind to be a good clinic. Because in order to be a good diagnostician, you have to understand patho mechanisms. You have to analyze you. For example, you could just memorize all the signs and symptoms associated with Docklands it's online. And then when you, you see all that stuff, you're like, oh, just apply Docklands as someone. But it's much better to not only have that memorized, but know why those things appear,

because you could take someone with Shula that didn't match that pattern, give them

song one, right. And kill them. Yeah. Yeah. Absolutely. No, you can, you can definitely shave time off people's life. If you can add days, you can very easily shave some off. I think

that's really important to remember, you know, so often we think, well, we didn't really help them, but we prepped, but we probably didn't hurt them. And that's, I think that's. Yeah, I think you're right.

Yeah. You don't know. You may have only shaved an hour off that person's life. Well, the outright

they wasted with you. I want to come back to mistakes for a moment because anyone that's been in practice for 20 years, um, we've made a lot of mistakes. I heard it the first week of school, when I first went to acupuncture school, there were some teachers that came in and they told us about cases that, that they did that totally went off the rails. Right? I think all of our teachers, we, we hear these great stories. I thought it was this. I gave him that this thing happened. Wheels came off the bus. I realized it wasn't sheet efficiency. It was blood stagnation. Give them this other formula, you know, they get better. And we love these stories, right? It's like, that's so cool. We love these stories, but here's the thing. When it's us, who's in the middle of treating someone. And we think we know what we're doing and we get very unexpected and, you know, frankly, bad results. It really is one of those moments where it's like, oh great. I get to learn something now, but rarely do we go to, oh, cool. I get to learn something. It's more like, oh shit. Now what?

Yeah. Yeah. I mean, especially serious case. Any advice

for us on when we come up to that moment of, oh, wrong, how do you sort of keep it together? Mind, thought emotions, take all of this and move it into something that can be helpful for the patient and help for you to learn something. Yeah.

Well, I think the first thing to remember is that you're always going to make mistakes. Medicine is really complicated. And so it's par for the course. So you need to cut yourself some slack. First of all. I saw my teachers, some teachers with 50 years experience and 50 years of experience in China is not like 50 years here. 50 years experienced there. It would be like a thousand years here. I mean, some of these doctors see a hundred patients a day, five, six days a week, and they hardly take holidays. So they're just, they see hundreds of thousands of patients in their career. If those doctors make mistakes and they definitely do, I've seen it, then it's perfectly normal that us lesser practitioners will make mistakes. So first of all, don't beat yourself up too much about it, but hold yourself to a high standard. I hold myself to a really high standard. So I'm constantly thinking, how can I do better? And even like I said, when I, when results are, are quote unquote, good. I still believe that I could have done better. Maybe I'm not capable of doing better, but there is something better. Sure. Just whether or not you can achieve that. But anyway, when you actually make an obvious error and people are getting worse, well, then you just, you need to step back. First of all, you need to be, you need to admit it like you, I see this a lot where people, and it's not just Chinese medicine practitioners, it's in the, in the alternative medicine fields. I would say, I don't know that MDs are saying this, but a lot of alternative medicine practitioners chalk up those kinds of things to healing crisis. And there is such a thing as a healing crisis, but not every patient. Uh, having adverse symptoms is a healing crisis. How do you

differentiate a healing crisis from bad treatment?

That's a really important question. So healing crisis, my theory about what a healing crisis is, I think it's first important to understand what that is, is that oftentimes patients have, they have a lot of excesses in their body, phlegm, blood stagnation, heat, whatever. And when you start to move those things around, dislodge them and you need to dislodge those things and purge them from the body,

right? You got to

metabolize it out. You have to first dislodge it and then get it to leave your body. But in that process, those things will circulate around the body and make people sick. From a Western perspective, there's a lot of metabolic waste toxins. For example, when people have blood stagnation, Well, since we're talking about it, when the blood stagnates, the blood is at once the delivery, people bringing oxygen, nutrients, more fluids, and all that to the tissues, it's also the garbage people taking away all the metabolic waste. So it delivers the good stuff. It takes away all the junk. If the blood stagnates, then all that junk starts to collect there. It's like the garbage man doesn't come around. So you have all this garbage collecting in your tissues. That's the stuff that's making you sick aside from the fact that not enough oxygen and nutrients are getting to your tissues. So there's starved, but there's also all this waste buildup. That's making things go haywire as well. So when you dislodge that stuff, it starts to circulate around the body. And if it doesn't leave quickly enough, or there's just a large amount of it, You'll have some symptoms from that. That's the healing crisis. That's what I think healing crisis is. You can minimize healing crises by promoting the rapid elimination of those waste toxins. When you go to do those kinds of things, to move those just lodge and move those things around, you gotta be sure to open the windows and doors. It's like when you're cleaning your house, you have to say that some carpet in your house, right. Or a rug, a rug in your house that's, you know, gets a lot of dirt and stuff accumulate. You don't pick the rug up and start beating it until all the windows and doors are open. If you beat the rug in the house with the windows and doors shut, now the dust is just stirring around. It's going to settle somewhere else. Right? So

you want to make sure your patients are pooping before you start moving too much blood.

Yeah. You gotta make sure all that stuff's coming up. You know, like I love to use dot child Hutong for that exact reason that It takes care of blood stagnation. It's got in it. You can use church, you could use buy shop, but I often will use Tricia, right. Because

for the blood stagnation guy.

Yeah. And then promote the liver detoxification pathways, right? So you're, you're using to help clean the bodies is pretty amazing. But anyway, healing crisis, you can minimize by promoting rapid elimination of those waste toxins. So a lot of people though, they, they do wrong treatment. And because for whatever reason, maybe they're, they're scared to admit that they make mistakes or they just think that they can't make mistakes. They think they're really great at, you know, being a clinician or they don't want to tell, admit it to the patients that they made a mistake. They just chalk those things up to healing crisis healing crisis. After the healing crisis, especially if you're good at eliminating those toxins from the body, the patients should feel better. That's one way, you know, they might feel amazing, but they might just feel a little bit better because you know, they might have a lot of problem going on and you just eliminated one little layer of it, but there should be some improvement after that, the tongue, the poles, the symptoms, the patients should feel a little bit. If they feel worse, okay, it's probably wrong treatment. And anyway, back to this thing about right diagnosis and wrong diagnosis, the odds are completely against you being right. So the odds of you, of it being a healing crisis versus wrong treatment, the odds are highly in favor of it being wrong treatment. So that's, I think really important to keep that in mind that it's easy to be wrong, but it's okay. Don't beat yourself up about it. And you can tell the patient. I mean, I'm super honest with my patients and I think they appreciate it. I'm just like, cause a lot of patients, especially around here in Portland, they know about healing crisis. They heard it before they've been to other doctors and they had the had symptom aggravation and the doctor's like, oh, that's a healing crisis. And then the patient was thinking, well, I don't know, because I don't feel better. So they know that they actually know the doctor is being dishonest or if not dishonest, then the doctors, it's not a good doctor because they don't realize it. So I'm just perfectly honest. I'm like, so that from the made you worse and that definitely happens to me. I make people worse all the time. I

mean, the reason I'm asking the question, I think because all of us do of course, you know, at some point all of us do and to be able to look at it and go, oh, that made you worse. We're getting back to pathol mechanism here, made them worse. And what way. Can be a really helpful question. Oh, it went like that. Oh, well we know not to do that. And that actually tells me something else

that helps you hone in on the proper diagnosis. It's an important thing to analyze carefully because it it'll help you get closer to the right diagnosis. If you, if you analyze it properly, you know, if you're honest with a patient, you say, look, let's see, you know, what are the signs and symptoms you have from these herbs? How did it go wrong? Or maybe it was a healing crisis. You analyze that with the patient, then you're like, okay. Yeah, that was a healing crisis. It looks like, just keep going with this formula. And I think you'll feel better or no, that's not a healing crisis. That formula definitely. There's something wrong with it. You know, stop taking it now and come in as soon as you can. And we'll, we'll reassess and change the formula. Patients really appreciate that. So I'm super honest with patients. If I make mistake, I'll just be like, that was a mistake. You know, this is, medicine's hard stuff. You just be honest with patients. They appreciate

it, especially when you're able to say it's wrong and here's the reason why it's wrong and here's what we're going to do

instead. That's the key is like to analyze, okay, what does that tell me if I gave this person, let's say that Shula patient, the deficiency, taxation patient. If I decide, oh, that patient's super weak. So their weakness and their taxation, that must be just due to cheat deficiency. And I taught a few of them and they get worse and it's like, okay, well maybe, maybe there is underlying deficiency there, but there's something else there. There's gotta be something else there. Otherwise my treatment would have worked so clearly you need to, you need to step back and reanalyze it, especially if you're treating. Isn't all over the place. And this is another thing we could talk about is when you're not super clear, sometimes you want to do something very unidirectional. You don't want a formula. That's all over the place. You do a little of this and a little of that. And a little of the other thing. Then when the patient comes back the next time, if it works, you don't really know why it worked. And if it didn't work, you don't know why it didn't work. So you're just back to square one. If you do something simple, straightforward unidirectional, then when the patient comes back, you can make sense of their response to it. You've got some data points to work with. Yeah, you actually have. Yeah, you can actually start making progress that way, as opposed to just starting over again. So analyzing those mistakes. It was a huge, important thing. And the first thing though, you gotta be able to be willing to admit it and not just chalk up everything to a healing crisis

and be a little kind with yourself in the process.

You cut yourself, some slack, don't beat yourself up. Cause everyone's making mistakes. You know, those 70 year old doctors they're making mistakes. So it's okay. You know, just, uh, learn from them,

learn from them.

Yeah. Yeah. That's the key learn

from? Well, holy smokes Greg. We're out of time. I hate to say, I hate to say that we're out

of time. Uh, well we can, we can talk another time. Let's talk another time to have another

conversation. Absolutely. Any final things you'd like to leave our listeners with before we say goodbye for today,

just got to keep studying. There's no end to it and stay humble. You got to stay humble. It's interesting. It at the college where I teach, I get students, you know, they, they give us feedback and I often will get the most of the students like me, but I there's a there's, you know, certain percentage of them that have called me arrogant and condescending. I don't know. Maybe I do come across that way. Most of the people that know me, well, wouldn't say that about me, but in the clinic, I certainly don't feel that way. I don't think I carry myself that way in the clinic. And I think any of the students that actually end up following me in the clinic, they see that I'm very willing to admit my mistakes and to just to stay humble, just be like, yeah, there's so much, I don't know. There's so much that all of us so much more for all of us to learn and yeah, we're going to make mistakes and. Don't try to bury them. Don't try to cover them up, do your best to face them and learn from them. The biggest learning experiences, most impactful learning experiences or from mistakes I've made. I've actually sent patients to the hospital before with herb formulas. You know, it never forget that because some patients, herb formula, and then you find out, you know, they had to go to the ER, that would keep you a little humble. Wouldn't it? Yeah. That's happened to me twice. And the most recent time was only a few years ago. Actually. That's a very interesting story, but I'd

love to get that story and we'll pick, maybe we'll pick up with that next time, the time break, send someone to the

hospital. Yeah. But I'm quick to admit that I always tell my students that I'm not ashamed of that. I wish it hadn't happened. But I'm sure I'm not the only one that's ever done that.

Yeah. Well, you know, you were one that happened to hear about it,

right?

Because I just happened to others of us and we just don't know, you know, a lot of times patients, they don't want to give you a bad news for whatever reason. Sometimes you got to dig it

out or they just won't come back. Well, there's that? Yeah. Yeah. The reason I know this is because that patient, even after that, she still loves me, which I just find kind of remarkable. You know, she still thinks I'm the best doctor around.

Alright,

we're going to, we're going to pick that up on the next time. We're going to start with that story, Greg. Thank you so much for taking the time today. It's been a, it's been a delight hanging out and geeking out on blood stagnate.

Yeah, thanks so much.