Dr. Victoria Maizes: Hi, Andy.

Dr. Andrew Weil: Hi Victoria

Dr. Victoria Maizes: Today we will be speaking with Dr. Leslie Blackhall, who is a Western trained physician with a passion for Tibetan Medicine. Well, not only a passion, she's really thoroughly steeped in it has studied it in India and been to Tibet, and, as you know, that is not a well-known system of medicine in this country, so very anxious to hear what she can tell us about it.

Dr. Andrew Weil: Well, let's get her on.

Intro Music

Dr. Victoria Maizes: Dr. Leslie Blackhall is a graduate of the NYU School of Medicine and serves as head of palliative care at the University of Virginia School of Medicine. She is a nationally known expert on end-of-life care. Leslie was called to this work when, as a medical student, she witnessed the reductive and often dehumanizing ways that seriously ill and dying patients were treated.
Her search for alternative approaches led her to Tibetan Buddhism and Tibetan Medicine. Welcome, Leslie.

Dr. Leslie Blackhall: Thank you very much I'm so pleased to be here,

Dr. Victoria Maizes: We're so glad to have you. You studied with Dr. Yeshe Donden, who's the Dalai Lama's personal physician. Maybe you could begin by telling our listeners a bit about your training in Tibetan Medicine.

Dr. Leslie Blackhall: Right.  Well, on a personal level I came to medical school, and
I had been very politically active. I met somebody named Joe Louitso, who's still He's a psychiatrist in New York, he teaches people meditative ways to handle their emotional to stress. At the time, we were getting in an argument about something, and he said to me…”so you call yourself ‘a radical’ and radical means “root” …is the root of suffering out there or in here?” And that that question blew my mind and actually changed my life because I had to realize that it's out there there's, you know, wars and famine. But the only reason it's out there, mostly, is because it's in here. There doesn't have to be those things. And that led me to study Tibetan Buddhism.

He introduced me to Robert Thurman, and Robert Thurman was the first person ordained as a monk by his Holiness the Dalai Lama, and he didn't stay a monk while he was studying as a monk, they decided he should study Tibetan medicine, so he studied with Dr. Yeshe Donden, and they became close friends, and the Institute he ran at that time the American Institute of Buddhist Studies every summer, had that Yeshe Donden there, and so. and and brought him back frequently, and I ended up going over to India, where he was in and studying with him there, I got my masters in theologic studies, and I learned Tibetan language, and we translated the root tantra, which is the main text. And then I've been working with the largest Tibetan medical group and medical school in China what was formally Omdo. So while I was studying as a medical student, I was also studying Tibetan, Buddhism and Tibetan medicine at the same time, and I always tell people that in a way that always gave me. you know, like a way to look at medicine from a little bit from the outside. I wasn't just sucked into that. I had like sort of Gregory Bates, and says it takes 2 to know 1, which means so, you know, if you're a fish, you don't know about water, it's only when you're not in the water, you know about water. And so I had like 2 ways of contrasting these very different views of living and dying, and and health and wellness, and what it meant.

Dr. Andrew Weil: Yeah, I am not very knowledgeable about Tibetan medicine, but my understanding is that it combines elements of Chinese medicine, Ayurveda, Shamanism, magic and that mix is quite strange to the Western world, and it's not very accessible here. What would you say? First of all, what do you think Tibetan medicine is good for when we refer somebody to it?

Dr. Leslie Blackhall: that's a really good question. I think in general, this goes for a lot of alternative medical modalities. Biomedicine is really crappy with things that span mind and body. There are a lot of illnesses, in fact, almost all illnesses, but there are a lot of illnesses for which that connect, you know, fibromyalgia, irritable bowel, chronic fatigue even depression, anxiety where mind and body are just absolutely intertwined.

We throw pills at those things, or we shunt somebody to somewhere else but the medical system itself doesn't have a way to make sense of that. And the other thing is biomedicine is not good at preventative medicine and wellness I mean there's a little bit of preventive medicine. I get my mammograms and etc., but really creating a sense of wellness health. And then there's something that really interests me is the Tibetan medicine because of it's very close connection with Tibetan Buddhism has a way of understanding what medicine is for. You know what health is for maybe. That I think we could sort of use in this culture, because there's a thing that bothers me is that there are a lot of things like meditation and yoga that have made it into this country and are really very popular. And that's good. But the way they've made it into this country is like if you do, yoga, you'll look better. You know what I mean, or you' be a little healthier, and your arms will be stronger, your you know your core will be better, or if you meditate, it's like almost a Mercenary type view of what it is.

Dr. Victoria Maizes: Transactional?

Dr. Leslie Blackhall: Transactional. Thank you. That's a much better word. But the purpose of meditation isn't just to give you health. In a way, the purpose of health is to give you meditation, because the goal of all humans is to become fully enlightened and living longer the purpose of living longer really is to have time for you to cultivate your mind and spirit, and as someone who deals with end-of-life care. I think, a lot about what it means what it is we want to do with the time we have. And that's the thing that really drew me to that kind of medical care. Is that that very deep connection, not just between mind and body, but mind, body, and spirit.


Dr. Victoria Maizes: I want to ask you to speak a little bit more about this interesting connection between the spirituality that comes from the Tibetan Buddhist practices and the way that influences Tibetan medicine because it sounds like you're making that quite primary which I think is not as common in another system of medicine that I could think of off the top of my head. Maybe Native American practices it's more primary.

Dr. Leslie Blackhall: Well, I think one thing that's important is that that Tibetan medicine didn't come to the West. It came to the West later. It's very textually based. So it was, in a way, because that was so isolated, very preserved. which is interesting. Tibetan medicine in a way is like, Ayurveda. And that's a humoral system right? There's the  3 humors of Ayurveda, vatta, pitta, and kapha. And those same 3 humors the balance of them is what you know is is considered help, and they're rlung, mkris pas, bad kan, and or the wind, bile, and phlegm in Tibet medicine. So the interesting thing is not to give a lecture in Tibetan Buddhism, but the cause of suffering in in Buddhist philosophy is mis-knowledge, ignorance about the world about the nature of reality, and that in turn causes the hatred it causes like greed or or craving or desire, and anger, and it causes like close mindedness and ignorance and prejudice, basically. So those 3 they're called the 3 poisons. But those 3 poisons are the basis of the 3 humors. That sort of like ambitious, striving, grasping clinging nature is rlung as wind and that sort of anger hatred. That's sort of the emotions in that range are mkhris pa. They are it. They aren’t just caused by it. They are the physical aspect of those mental states. And then you know, bad kan or phlegm.
as I call it is, ignorance and prejudice, close mindedness. So those things have a really, close connection, They are each other. if that makes sense to you. And I once asked one of the Tibetan doctors, since changes in your mental state, or cultivating anger over a lifetime, and maybe watching Fox news or something, getting more and more angry sorry if that little thing getting more and more angry would inflame, and raise that particular humor and set it off an imbalance. But can it go the other way? If you do something to improve the balance of your 3 humors, does it go back the other way? And Yeshe Dundan, and I believe it was who said to me, It's like the tree and the fruit. It doesn't go the other way as much okay. May, the root of everything of these physical states really is those mental states. And so like, Ayurveda for health Tibetan medicine is looking at the balance of those humors. But I don't know if anybody would be familiar with it but Freud said that what he was trying to achieve with psychoanalysis is to get people to a normal level neurosis. Okay? So in a certain way that that you know enlightenment, you know eliminates those 3 emotions.

So that kind of health that's balanced is a little bit different then sort of the ultimate goal of human beings. And so really, the only healthy person is the Buddha, and the only doctor is the Buddha who can teach you to go beyond being a normal level of a person who is still someone sort of stuck in in this world in somsara. So that's that's sort of an overview of what that looks like. And then the idea behind what Tibetan doctors do is that they're trying to bounce those humors. But everybody is born, not being a little bit out of balance, like you have more of one than the other. Nobody is born with like a perfect Balance of those things, and people tend to like do things that cultivate that. So physicians are like they're trying to get good grades so they can get to college, and then they're working hard and grasping and hoping to get into medical school and working hard. And you know all of that striving and ambition that goes on and on. It's never enough. You get a fellowship that's great, and then you have to get a thing, and then you want to be the section head, and then you want to be the Dean, which I would never be the dean, I’d put my head in the blender okay, but you know what I mean. That kind of striving would intend to you know inflame that particular thing, and I've said before, somebody who doesn't read anything who only gets who doesn't ever try to learn something sort of different, and who's uninterest in things they may be that way because they had a tendency for that when they were born, but that's a mental state that can do that. And in addition, of course, there are foods that that sort of stir up and increase the rlung or the wind in their foods. various things in the outside world that can either help or hurt it. And, so here's the connection with um Chinese medicine. So most of the remedies of that medicine are these herbal pills that have, like some of them, at 20 different herbs to balance them out and they have a lot of herbal baths and steam and herbal compresses, but they also do like in Chinese medicine, acupuncture amaxa. And I think in terms of theory, they have. the elements theory is very important in Tibetan medicine as well, and in Tibetan pharmacology. So the earth, air, wind, and fire those sort of elements.

Dr. Andrew Weil: Let me ask you about something a little different Tibetan Buddhism has a strong focus on death and dying. And I wonder how that's influenced your work in end of life care?

Dr. Leslie Blackhall: I actually wrote a book chapter in the most recent handbook of phenomenology with Dr. Gelson about this issue. So we're working together to try to sort of parse it out. Oh, you've got a very cute dog behind you. And he told me once that he hated death certificates. And so it took us a while to figure out you know why… And the the problem for him was that there's a cause of death. Okay, from the Tibetan point of view. From the Buddhist point of view, the cause of death is life, but it's very important. Death is intrinsic. But for us in biomedicine death is extrinsic. That's why we have this whole thing about the causes of death. We're gonna beat cancer. We're gonna beat this. We have a war on that and we have made a lot of, you know strides. But at the end if people are continually hoping for the next miracle, whether it's a you know, a miracle from God or a miracle from the National Cancer Institute. So I give a talk called a Lazarus and the Mustard Seed and the story of Lazarus, which is in the Bible, is a story of someone who dies, and Jesus raises him from the dead to show the power and glory of God. And it's a beautiful story. It's actually one of the more beautiful know passages in in the Bible. There's a similar but way different story in Buddhism which is about a woman whose baby has died, and she gave birth, and the baby died when he was very young, and she's crazed, and she's going from place to place and doctor to doctor, carrying her baby saying, ‘You have to help my baby. You have to fix my baby.’ So finally someone points towards the Buddha and said, ‘Go talk to that guy’ and he says to her, ‘I can bring your baby back if you can bring me a mustard seed from a house where nobody there has known anyone who died’, and so she goes from house the house, everybody says, ‘oh, I'm so sorry. You know my son died or my brother died, and my father died’, and she spends a whole night doing that, and she realizes that death comes for everybody. And so she buries her baby and she becomes a disciple of the Buddha and I think you can say that's quite a different idea of dying.

Dr. Victoria Maizes: It's a really beautiful contrast. And I want to ask you a question. For 10 years I taught at a retreat program for women who had a cancer diagnosis. It was at the Shabbala Mountain Center in Colorado, which is a Tibetan Buddhist retreat center. And it was a wonderful, you know, a gift, a pro bono program. It was called Courageous Women, Fearless Living, and I have to say I love the name to me that is evocative of some of the chance that focused on fearlessness and courage, and kind of supported some of that attitude in the women that feels different to me than you know this perspective, that death is intrinsic, because certainly these women, some of them knew they were going to die. And that was why they were there. But others were absolutely in a different stage perhaps of their cancer, a different stage of their perspective on even advanced cancer. And they were, you know looking for their courage to address an illness.

Dr. Leslie Blackhall: To fight.

Dr. Victoria Maizes: Yes, to fight.

Leslie Blackhall: So I just want you to know I did an anti-hope TED Talk it's called ‘Living Dying the Problem with Hope’, And so here's the problem, if what's getting you through your fear of you know it's scary as hell, you know. My parents died of cancer, you know.  I will probably die of cancer. I always say to people, this is how palliative care doctors think if they cured cancer, I'd be really glad. And my next thought would be. I guess I have to die of dementia because people you know what I mean… people die. Most people don't dive aids anymore. But they're not going to live forever anyway. So if what's getting you through is hope your hope of living longer, that can help. But as you get closer to the end of life, and you get more scared. So that hope is also fear. I just want to say that because, I'm not hoping to live till Christmas. My patients often are hoping to live till Christmas, because I'm not afraid I'm not going to live till Christmas. Do you see what I'm saying. I don't hope the sun will be up tomorrow. I assume the sun will be up tomorrow. So that hope is something they're using to press away in a way, the fear. And that's okay for a while, and it can be really good. But the closer you get towards the end of life, the more it. And that's your tool, the more you need that hope, and the more you're pinning hope on things that are less and less of a chance of helping. And that's sort of how you end up in the ICU at the end of your life.

And so hope and fear our emotional states right? Their emotions about the future. In fact, they're not that helpful. You know what helps to look at what's going on in your body and try to in your mind and try to help that on a day-by-day basis you can hope to live longer. You can hope to have a better life. But the question I ask my patients is, “what are you hoping to do with the time you have? However long it is” right? Let's make that good. So people don't spend the end of their life going to one doctor after the other and not being with their family.

So that's a question we should all ask ourselves what do we hope to do with whatever time we have? And let's do it now. Forget your bucket list by the time you want to do your bucket list because you're got advanced cancer, you're too sick to do your bucket list. If you really want to go do something, do it now. There's a meditation, but it's also saying in Tibetan Buddhism, which is, death is certain it's timing's uncertain each day it takes us one day closer to death and in the end the only thing that helps is our spiritual practice I don't think that's depressing. That shows you who I am. But I do think, trying to let go of that feeling of I feel sad when people are fighting because if something bad happens, if they decide to stop doing chemotherapy, are they a quitter? Do you see what I'm saying that's not true, any of it.

Dr. Victoria Maizes: Oh, I agree with you I think finding that place,

Dr. Leslie Blackhall: Look, it's very hard and I think whatever tools you need, you need them, but you need to to drop the tools when they're no longer serving you, and you have to see how much that focusing on that fighting hope thing might be sort of a tense energy and going into the fear a little bit, looking at that fear, I always tell people it's like, if you want to play. You want to be in a rock band. Okay, you play the guitar, and then you're hoping that you'll be like a rock star, and everybody loves you, and you're fearing that you'll everybody will hate you but none of those things helps. You gotta look and say, how's my guitar playing?

Similarly, you're hoping you'll live till your grandchildren graduate from college, and you're afraid you'll die tomorrow. In the meantime, those are just thoughts you're having.
How do you need to improve your nutrition.

Is the course you're on of whatever treatment you're on helping you and having, like an honest look at yourself.

That's what helps being able to really look at what's going on in your mind, body, and spirit it's impossible to completely let go. But try to just notice that your mind is being dominated by this emotional state, this probably not doing you a whole lot of good.

Dr. Victoria Maizes: Yeah, the Tibetan Buddhist teacher at the Retreat, Judy Leaf, wrote a book called Making Friends with Death. So that perspective was also there.

Dr. Leslie Blackhall: I would just say that from my perspective accepting doesn't mean you have to like it? Do you know what I'm saying… you can hate it. You just have to acknowledge that it's there.

Dr. Andrew Weil: Here's a practical question, how accessible is Tibetan medicine in the US?

Dr. Leslie Blackhall: It's not as accessible as it could be, partly because, unlike Chinese medicine, there's no way of being licensed in it. I will say there's somebody named Alex Tokar, in New York. I don't want to be an advertisement for him, but he's quite good, and there is also.
I think, and I'll be happy to give you these links. So there's an Institute. I think it's Samshung. I'm not sure how to pronounce it. They used to be the only Tibetan Medical School in the States back in the day. And it was in Western Mass. And I noticed now, when I was looking at their website, that they're now online. And it has that website has a lot of links. So I can probably give you a lot of different links that can allow your listeners if they want. But the problem with Tibetan medicine. One of the problems is that the herbal remedies which are the basis of their treatment are their medications, and they're not like FDA approved. Let's put it that way.

Dr. Victoria Maizes: Can you give us an example using Tibet medicine where this very different approach from western bio medicine would be evident?

Dr. Leslie Blackhall: So I want to say that I do not utilize Tibetan medicine because they study as long as I did. I am very respectful of the amount of study and practice it takes. They go to 4 years of medical school. They do apprenticeships, they learn a lot of stuff about diagnostic techniques. However, I can tell you things I've seen. To give you an example rlung people who have an overactive rlung, that's wind. So these are people tend to be a little anxious or ambitious, and worried that they don't have enough they aren't enough. So the way of looking at the 3 humors, I think the better way is looking at them at 3 functions.
So wind, rlung is nervous system, mkhris pa or bile sort of phlegmatic things.
And bad kan is sort of like fluids that hold and lubricate. So, for example, in your stomach from Western medicine is like sort of more anatomic idea.

But for Tibetan medicine. There's the rlung wind that controls the contractions of the stomach, and then there's the mkhris pa, the bile, which is not just the bile comes from the gall bladder would be the digesting, and the bad kan is the fluid. That sort of the neutral fluids that hold it all together just to say this. So they tend to be, on the one hand, sort of often very physically active and mentally sort of anxious and driven and they would be prone to anxiety or panic tax, mental states and certain types, maybe of irritable bow. Where you have, diarrhea in a lot of diarrhea. Because you're the nervous system aspects of your intestine are an overdrive. Okay. So the way to help this, if it's sort of a, you know, rlung, predominant thing is on number one to cultivate mental states that are calmer, that helps calm you down help relax you and helps notice how your mind is spinning like that.

And the second thing to seek out behavioral things like It would be better for a rlung person to be where you are, Andrew in Tucson, where it's a 110. Then somebody who’s bile which could file is very fiery, you know you might need to be cooled down and then there are foods tend to promote one humor or the other, and so you'd have to avoid those ones. And then there are medications that might sort of cool down that. I've seen people who've told me, and this is in the Tibetan Medical outpatient setting how much improvement they've had from that approach. These are Tibetan people by the way.

Dr. Victoria Maizes: Can you speak to “okay you have excess wind.” What foods would you recommend to that person?

Dr. Leslie Blackhall: This is where the 3 the humoral system takes over.
So earth, air, wind, fire, and sometimes spaces put in there right? So rlung, or wind is obviously air, and bile is fire, and earth is water and bad kan.
So actually, there are these tastes, like sweet, sour, salty astringent and each of them is associated. Each of those tastes is associated with different elements. So, for example, sweet food is earth and water.

So yay rlung, it's okay to eat sweet food, but like maybe for other ones like phlegm, that's not a good thing to eat, right? So it's the that's it's true of herbs, too, when they want to know if they're in a different place what the potency of that herb is tasting it is one way to know, because the taste of the herb tells you how it works. That the basis for which they'll give you dietary changes. And it's it's more than that, you know. So actually, Dr. Konchok, who's both a monk and a Ph. D. From UCLA, and a Tibetan traditional physician gave us a whole sort of chart with the different potencies of those things, that's the basis on which they would sort of give you that advice for example, if you have a bile disorder of spicy food, so probably not the thing, but it might be good, for people an excess of phlegm. Phlegmatic is a term that comes from the Greek system was also humoral. in addition, the other thing I've seen is people. This was also when I was in Tibet, in in LOCATION They have these herbal baths and herbal compresses, the better external therapies that seem to be very effective, that external placement for that type of joint pain rather than you know pills although often those are diseases of phlegm, and they do take pills internally as well. And so also those are good for skin diseases and things like that.

But one thing I just want to mention, because Andrew mentioned it is that the other interesting thing about Tibetan medicine is they have, like four basic causes of disease when you get sick of imbalance. One is from a past lifetime karmic, and that's sort of like genetic disease. In other words, you're born with something like that. And so what we call genetic disease they would probably think of karmic disease.

And then the second is disease of one lifetime. So that's if you spend your whole life cultivating like I said me as a doctor, I had to work to not be that person who was always like meeting and running around and trying to get everything and trying to do everything and you do that over your whole lifetime without cease then you can end up with certain kinds of illnesses which are treatable but a little harder, because they're deeply rooted. And then there are diseases that are so more superficial, what we would consider what we consider food poisoning or something like that. But how happen from like, maybe, you know, just more recent things like that. Does that make sense? But the fourth one is spirit caused. That's what you were thinking about. Andrew. So the thing is Tibetan medicine before you know the Chinese invasion 50% of all of the physicians were monks.

This is not as true now. But those physicians monks are not are not the ones who are going to teach you how to do the meditations you need, because it's assumed that you have that resource because it was true in that community. So people, especially with karmic diseases that have to be very hard to treat, or maybe not treatable, except for cultivating meditation and it may take another lifetime for you to but sort of develop that that meditation. similarly, there are shamanistic, practitioners in Tibet, or there were, and I suppose there still are, and if they have a spirit caused illness you know that's also someone you would refer out. And interestingly. the diagnostic things are like your analysis. And this is pulse, this is why I'm doing this thing. And there's a there's a description of you know what the urine looks like of somebody as a spirit caused illness and and sort of how you can tell which spirit it is. And the Yeshe Donden told me, when he came to the States, that he sometimes felt, especially people with serious mental illnesses had a spirit called caused illness, but he often didn't say anything about it to them, because he didn't know if it would be accepted, and he didn't know what kind of spirits we have in this country. And we don't have the resources that they had. So this is just tells you there's a way in which some of these things were embedded in there, and one of the conversations I've had with some of the people who are trying to practice in the States is a bit of that sort of at least the meditative part in and be more explicit about it than you had to be in Tibet, and I think that's what's happened now is that they have to be a little more explicit about this is the type of you know meditation. If you're interested, but some of the people are Buddhist, but they have to find practices within their own.

Dr. Victoria Maizes: Well, I think this has been so fascinating, and I so appreciate your willingness to share some of your wisdom about this traditional system of medicine that really is not well known here in the West. and I think you've given us a sense also of its complexity and the context in which it flourishes. And so, therefore some of the challenges of bringing it to the West.

Dr. Leslie Blackhall: Yeah, I think that's true of many systems of medicine and I think I have a lot of respect for anybody who delves into really learning how to do those
I think what's happened in this culture around having real medical schools where people can learn, like your place, Andrew, where people can really learn more in depth about these, instead of doing a weekend, I think it's wonderful that we're having you know, sort of a more in depth way of people understanding it. And I think, Andrew, you've really been one of the people who's
made that real.

Dr. Andrew Weil: Thanks. We are trying. And I would love to include more information about Tibetan medicine in our curriculum.

Dr. Leslie Blackhall: So happy to do it. And we'll work on that. So thank you guys so much, and You have very cute dog is last thing.