physical examination

[Guest guest]

PCOM has decided to offer advanced training to clinical supervisors in

several areas of physical examination, including orthopedic and

neurological testing, as well as the use of stethoscope and otoscope to

evaluate cardiovascular, respiratory and EENT complaints. This type of

evaluation is technically part of our scope of practice in CA.

Students receive a modicum of training in these areas and some

instructors put considerable emphasis on them, esp. the ortho/neuro

testing. Thus students (and rightly so) expect to practice these

techniques during their clinical internship. However there are several

stumbling blocks and reservations I have. first, the actual training in

these areas for current students does not come close to that obtained by

medical doctors or chiros. Even with extensive training in these areas,

many authorities believe that new grads from medical school are very

weak in these diagnostics and tend to favor objective labs and imaging

instead. Second, many clinical supervisors, especially if trained

outside CA or long ago, have no ability at all in these areas. I

question whether four hours of CEU a couple times a year can accomplish

anything but a false sense of competence in these areas. While we are

primary care in CA, most of our patients are under the care of MD's. I

think we should rely on the experts to do this type of diagnosis. We

are already struggling to impart competence in TCM diagnostics to our

students. In my opinion, people who have respiratory, cardiac or

chronic pain complaints should be evaluated by an MD. I'd like to share

a story.

 

Last year, a patient in my clinic was seeing a fellow acupuncturist for

chronic pain. For about a ear, she traipsed around to various

professionals, including chiros, masseuses, shrinks and other acus

outside my office. she received an assortment of tests, some of which

included biomedical type diagnostics by undertrained personnel. she was

given TCM patterns, labeled as fibromyalgia and also chronic depression,

candida, food allergy, etc. At some point, by chance, a very allopathic

style ND took a look at her file and was quite alarmed. She recommended

a simple blood test (CBC and chemscreen) to her more holistic

colleague. the results came back with extremely elevated blood calcium,

which is often an indication of bone cancer. this young mother of a

young child was soon diagnosed with advanced multiple myeloma. While

she would have likely died anyway from this condition, the delay in dx

due to widespread shortsightedness shortened her life by several years

perhaps, depriving her son a mother and her of the time to come to terms

with her disease and make arrangements. This underscored to me that we

are not qualified to be the arbiter of these type of medical decisions.

Any patient who presents with worsening chronic illness despite our TCM

care should be evaluated by an expert to rule out cancer or hear disease

or emphysema or whatever. this woman had all the requisite ortho/neuro

testing and the convenient fibromyalgia dx. All that was required was a

judgment call that could have been easily made by an second year med

student. Four hours of CE will likely cause, not prevent, more of the

same. TCM is an extensive undertaking itself. that is where we should

put our focus. Do we really want to be jacks of all trades and masters

of none?

 

--

 

Chinese Herbal Medicine

 

[Guest guest]

 

TCM is an extensive undertaking itself. that is where we shouldput our focus. Do we really want to be jacks of all trades and mastersof none?

Being a DNBAO (Diplomate of the National Board of Acupuncture Orthopedics) I

feel that basic physical exam skills should be manditory. My experience is that acu schools do not teach you

when to refer. Learning how to do the basics will only make it easier for you to determine when to send someone

on to another practitioner, and you only look that much better to other practitioners if you can say that the patient failed

a particular test in your office and could they check it out further.

 

I don't think knowing how to do basic physical exam will predispose you to making poor diagnoses, just the opposite.

I do think the example you gave only further supports that the acupuncturists that treated that woman would have better served

her if they had this knowledge. Obviously nothing in their previous TCM training told them they should refer. What would you put in place instead of this training that would adequately prepare individuals to recognize serious illnesses.

 

I don't know how much M.D.'s actually practice these techniques, they use the labs and special diagnostics because that is what they do most of the time throughout their training, no? I know some orthopods do a lot of physical exam, how about the others.

 

You are right in that four hours will not be enough, but I think it is still worth doing. There are a number of year long courses out there currently, Alon teaches one. I would hope that the doctoral degree will implement some of this too.

 

Sean Doherty

Todd Thursday, November 09, 2000 1:19 PMcha physical examination

PCOM has decided to offer advanced training to clinical supervisors inseveral areas of physical examination, including orthopedic andneurological testing, as well as the use of stethoscope and otoscope toevaluate cardiovascular, respiratory and EENT complaints. This type ofevaluation is technically part of our scope of practice in CA.Students receive a modicum of training in these areas and someinstructors put considerable emphasis on them, esp. the ortho/neurotesting. Thus students (and rightly so) expect to practice thesetechniques during their clinical internship. However there are severalstumbling blocks and reservations I have. first, the actual training inthese areas for current students does not come close to that obtained bymedical doctors or chiros. Even with extensive training in these areas,many authorities believe that new grads from medical school are veryweak in these diagnostics and tend to favor objective labs and imaginginstead. Second, many clinical supervisors, especially if trainedoutside CA or long ago, have no ability at all in these areas. Iquestion whether four hours of CEU a couple times a year can accomplishanything but a false sense of competence in these areas. While we areprimary care in CA, most of our patients are under the care of MD's. Ithink we should rely on the experts to do this type of diagnosis. Weare already struggling to impart competence in TCM diagnostics to ourstudents. In my opinion, people who have respiratory, cardiac orchronic pain complaints should be evaluated by an MD. I'd like to sharea story.Last year, a patient in my clinic was seeing a fellow acupuncturist forchronic pain. For about a ear, she traipsed around to variousprofessionals, including chiros, masseuses, shrinks and other acusoutside my office. she received an assortment of tests, some of whichincluded biomedical type diagnostics by undertrained personnel. she wasgiven TCM patterns, labeled as fibromyalgia and also chronic depression,candida, food allergy, etc. At some point, by chance, a very allopathicstyle ND took a look at her file and was quite alarmed. She recommendeda simple blood test (CBC and chemscreen) to her more holisticcolleague. the results came back with extremely elevated blood calcium,which is often an indication of bone cancer. this young mother of ayoung child was soon diagnosed with advanced multiple myeloma. Whileshe would have likely died anyway from this condition, the delay in dxdue to widespread shortsightedness shortened her life by several yearsperhaps, depriving her son a mother and her of the time to come to termswith her disease and make arrangements. This underscored to me that weare not qualified to be the arbiter of these type of medical decisions.Any patient who presents with worsening chronic illness despite our TCMcare should be evaluated by an expert to rule out cancer or hear diseaseor emphysema or whatever. this woman had all the requisite ortho/neurotesting and the convenient fibromyalgia dx. All that was required was ajudgment call that could have been easily made by an second year medstudent. Four hours of CE will likely cause, not prevent, more of thesame. TCM is an extensive undertaking itself. that is where we shouldput our focus. Do we really want to be jacks of all trades and mastersof none?--DirectorChinese Herbal Medicinehttp://www..orgChinese Herbal Medicine, a voluntary organization of licensed healthcare practitioners, matriculated students and postgraduate academics specializing in Chinese Herbal Medicine, provides a variety of professional services, including board approved online continuing education.

[Guest guest]

, " Nashua Natural Medicine " <

sean@n...> wrote:

 

What would you put in place instead

> of this training that would adequately prepare individuals to recognize

serious illnesses.

>

 

Something like the warning on OTC medication that if symptoms persist

for a certain length of time despite ostensibly correct TCM tx that the

patient should be referred for medical evaluation. I have seen

training in physical exam go to either extreme whilst working in

training clinics. Patients are frequently referred to cardiologists

based on an erroneous evaluation of the heart. I have yet to see an

acupuncturist correctly catch an arrythmia and thus have caused many

patients undue stress. In this case, the pateint had no chest

complaints or evenother serious sx, yet the Acu's listening to the

chest resulted in the referral anyway. I have literally seen this

about a 100 times in 10 years. conversely, I have seen examination of

the throat or ears lead the acu to give a clean bill of health to

pateints with strep infection on a dozen occasions. Most recently,I

was horrified to learn that a patient with sudden onset sore throat was

being treated for yin xu for over a month. I sent her for medical eval

immediately, at which time strep was diagnosed. the patient did not

present with severe inflammation or white spots on throat, so the acu

erred, when common sense should have prevailed.

 

I personally have 2 years of medical training in physical exam, lab

test and x-ray, equivalent in hours to many medical doctors. what I

lack (and can never achieve) is the thousands of hours of grand rounds,

internship and residency that is critical to actually putting this

basic training into viable clinical practice. I have spent my time

learning to look at tongue, feel pulse and assess interviews from a TCM

perspective, not mention reading case studies and classics. I could

have spent my time doing the other, but I don't think I would be very

good at TCM, then. Having said that, I have no problem with people

pursuing a medical acupuncture route and focusing on modern diagnostics

instead. Perhaps we should have different tracks for those who want to

go one way or the other.

 

[Guest guest]

 

Something like the warning on OTC medication that if symptoms persist for a certain length of time despite ostensibly correct TCM tx that the patient should be referred for medical evaluation.

 

I don't see this as practical.

 

In my practice I work with my wife who is a naturopath and I refer to, or consult with, her all the time. I send people back to their PCP's to get second opinions frequently too, and the patients appreciate that.

The physical exam that I mostly do is orthopedic. I do opthalmic and otoscopic exams but to a level that I feel comfortable. I had one patient say they had a decrease in their hearing, so I checked their ear and it was blocked with wax. This is a simple thing to do, and is much better medicine than treating someone for a month, realizing you aren't getting any results, and then referring for something that could have been cleared in one or two visits or with home treatment (mind you, you still have to treat later for why the ear wax is building up in the first place ). So, I guess what I am saying is that there are some physical exam techniques, as you are well aware, that are easy to learn and give a wealth of information, and don't have to detract from one's TCM studies. However, I don't think cardiac evaluation is one of those things, at least it is not something I feel very competent at doing. I think physical exam like cranial nerve exams, orthopedic tests, etc. can be integrated without too much hardship. I don't think you have to learn one at the expense of the other.

 

 

< I sent her for medical eval immediately, at which time strep was diagnosed. the patient did not present with severe inflammation or white spots on throat, so the acu erred, when common sense should have prevailed. >

 

I am not sure you can teach common sense. Without it people will make mistakes regardless of how much training they have.

 

wrote

<I personally have 2 years of medical training in physical exam, lab test and x-ray, equivalent in hours to many medical doctors. >

 

Then I am sure you don't even realize how much you draw on this information in your practice- it has become subconcious.

 

 

Sean Doherty

[Guest guest]

, " Nashua Natural Medicine " <

sean@n...> wrote:

 

>

>

wrote

> <I personally have 2 years of medical training in physical exam, lab

> test and x-ray, equivalent in hours to many medical doctors. >

>

> Then I am sure you don't even realize how much you draw on this information

> in your practice- it has become subconcious.

>

>

> Sean Doherty

 

You are right about that, but I feel it mainly makes me cognizant of

the need to refer in cases when some of my colleagues would continue to

treat. However, I probably do unconsciously rule out serious illness

at times based upon my training. However, I would still be quick to

refer if prolonged tx was unsuccessful. I have to admit that the

multiple myeloma case I mentioned was never seen by me personally, so I

was unaware of the severity till it was too late. My general tendency

to look for horse rather than zebras in clinical practice had certainly

led me to conjecture that this woman was probably suffering from

depression. this was based on waiting room observation. I like to

think that if she had been under my care, I would have made a different

assessment and acted accordingly. thanks for your input. I have often

worked with ND's in my clinic until recently and have found their input

in these areas invaluable.

 

[Guest guest]

My experience in this was supervising in the student clinic and seeing a patient

where " something was wrong " . I don't remember the specifics but it had something

to do with a recent illness history and her pulse was incredibly " soggy " , her

energy sapped. I brought another

supervisor in (Chinese, if it matters) and we decided not to treat, mainly to

" scare " the woman into seeing an MD, whom she had been seeing previously.

She promised to see the MD. We later found the MD did a CBC and the woman was

put the hospital with a septic (?) infection throughout her upper chest and on

an antibiotic drip for 2 weeks.

We lucked out...

We could have treated ordered a test but I have a feeling that the process was

greatly speeded up by the direct MD exam.

 

doug

[Guest guest]

the delay in dxdue to widespread shortsightedness shortened her life by several yearsperhaps, depriving her son a mother and her of the time to come to termswith her disease and make arrangements.

>>>This is the largest growing field of malpractice. 4 hr are definitely not enough. But we have to make a decision do we give up primary care or boost our education. It is very possible to teach an adequate P and H as well as sceenoing examination to allied health professional and make them safe

alon

[Guest guest]

? I know some orthopods do a lot of physical exam, how about the others.

>>>>Unfortunately physical examination is not practiced enough especially by orthopods

alon

[Guest guest]

I have yet to see an acupuncturist correctly catch an arrythmia and thus have caused many patients undue stress. In this case, the pateint had no chest complaints or evenother serious sx, yet the Acu's listening to the chest resulted in the referral anyway. I have literally seen this about a 100 times in 10 years. conversely, I have seen examination of the throat or ears lead the au to give a clean bill of health to patents with strap infection on a dozen occasions. >>>It is worse than theta I have yet to have acup identify the symptoms of an acute non-classical heart attack. And this weekend at the AAOM meeting actually heard of an acupuncturist that missed a heart attack in her office.

Strap thought can not be ruled out by physical examination. A quick strap test is easy to do in office

alon

[Guest guest]

on 11/16/00 2:37 PM, alonmarcus at alonmarcus wrote:

 

I have yet to see an

acupuncturist correctly catch an arrythmia and thus have caused many

patients undue stress. In this case, the pateint had no chest

complaints or evenother serious sx, yet the Acu's listening to the

chest resulted in the referral anyway. I have literally seen this

about a 100 times in 10 years. conversely, I have seen examination of

the throat or ears lead the au to give a clean bill of health to

patents with strap infection on a dozen occasions. >>>

It is worse than theta I have yet to have acup identify the symptoms of an acute non-classical heart attack. And this weekend at the AAOM meeting actually heard of an acupuncturist that missed a heart attack in her office.

Strap thought can not be ruled out by physical examination. A quick strap test is easy to do in office

alon

 

(Z'ev( While I agree with Alon that we should have our profession learn or have access to these tests, my experience, both in my own practice and some of my colleagues, is that accurate pulse diagnosis and symptom differentiation can definately reveal acute life-threatening pathologies. I have sent patients for testing or hospital after pulse readings where ovarian cancer was found in one patient with a prominant, choppy pulse in the L chi position, one patient with slippery, wiry pulse, abdominal pain and heat radiating off the abdominal to the emergency room for emergency abdominal surgery (after Western testing confirmation in all cases), and a patient for EKG's and other heart tests after feeling a segmented heart pulse where the two chambers were prominant in the cun position on the left, with a rough quality indicating poor blood circulation in the heart. This patient was found to have mitral stenosis and regurgitation of blood between the heart chambers.

 

I add this comment simply to point out that our TCM diagnostic skills, especially pulse diagnosis, also need upgrading as well,and wanted to share a few of my own experiences. My own skills are also in need of further refinement. I struggle daily with my pulse and diagnostic technique, and, yes, I have missed things as well. As Bob Flaws says, 'human error is part of diagnostic judgement. I have also, however, caught things that Western docs have missed, and sent them back in for further testing.

 

On learning more sophisticated pulse skills, Dr. Hammer/Rory Kerr's workshops are a nice place to start.

 

 

[Guest guest]

On learning more sophisticated pulse skills, Dr. Hammer/Rory Kerr's workshops are a nice place to start.>>>>Dr Hammer had a very interesting lecture at the AAOM conference. Like me he was saying that much of CM is not relevant to modern times. His point was that the classics are politically correct literature (i.e. imperial approved writing) and that most of "effective" systems of CM have only an oral tradition.

Alon

[Guest guest]

on 11/17/00 9:07 PM, alonmarcus at alonmarcus wrote:

 

On learning more sophisticated pulse skills, Dr. Hammer/Rory Kerr's workshops are a nice place to start.

>>>>Dr Hammer had a very interesting lecture at the AAOM conference. Like me he was saying that much of CM is not relevant to modern times. His point was that the classics are politically correct literature (i.e. imperial approved writing) and that most of " effective " systems of CM have only an oral tradition.

Alon

 

I may not agree with everything he says. . . .. but I would really like to get access to his lecture notes or tapes (and I look forward to his pulse book). Can you help me here?

 

Z'ev

[Guest guest]

At 9:07 PM -0800 11/17/00, alonmarcus wrote:

On learning

more sophisticated pulse skills, Dr. Hammer/Rory Kerr's workshops are

a nice place to start.

>>>>Dr Hammer had a very interesting lecture at

the AAOM conference. Like me he was saying that much of CM is not

relevant to modern times. His point was that the classics are

politically correct literature (i.e. imperial approved writing) and

that most of " effective " systems of CM have only an oral

tradition.

----

 

Just in case there is any doubt, or anyone cares, I'd like to

disassociate myself from this point of view. CM provides a very wide

and flexible medical toolbox. If some parts of it are not relevant

now, then there are plenty of others that are; that is one reason

that patients seek our services. There are parts of Western medicine

that were relevant 50 years ago that are not now - so what? To argue

that the classics of CM are problematic because they contain some

language honoring the emperors is nonsense, and in any case is not

relevant to works such as the shang han lun; most of the well known

teachers who have passed down Chinese medical knowledge, orally or in

writing, have been well versed in the classics. The study of the

classics is part of the development of a well grounded and

independent medical mind, and is one guard we have against placing

too much reliance in self promoting authorities. If we are to improve

CM and increase its relevance, we had better have a good

understanding of it, and that would have to include study of its

literature. I have no argument with what you do Alon, which seems to

me to be a very worthwhile attempt at complementing and expanding our

system of medicine by finding bridges to biomedicine and osteopathy;

what I challenge is the need to negate Chinese medicine and its

history.

 

Rory

[Guest guest]

on 11/18/00 9:17 PM, Rory Kerr at rorykerr wrote:

 

At 9:07 PM -0800 11/17/00, alonmarcus wrote:

On learning more sophisticated pulse skills, Dr. Hammer/Rory Kerr's workshops are a nice place to start.

>>>>Dr Hammer had a very interesting lecture at the AAOM conference. Like me he was saying that much of CM is not relevant to modern times. His point was that the classics are politically correct literature (i.e. imperial approved writing) and that most of " effective " systems of CM have only an oral tradition.

----

 

Just in case there is any doubt, or anyone cares, I'd like to disassociate myself from this point of view. CM provides a very wide and flexible medical toolbox. If some parts of it are not relevant now, then there are plenty of others that are; that is one reason that patients seek our services. There are parts of Western medicine that were relevant 50 years ago that are not now - so what? To argue that the classics of CM are problematic because they contain some language honoring the emperors is nonsense, and in any case is not relevant to works such as the shang han lun; most of the well known teachers who have passed down Chinese medical knowledge, orally or in writing, have been well versed in the classics. The study of the classics is part of the development of a well grounded and independent medical mind, and is one guard we have against placing too much reliance in self promoting authorities. If we are to improve CM and increase its relevance, we had better have a good understanding of it, and that would have to include study of its literature. I have no argument with what you do Alon, which seems to me to be a very worthwhile attempt at complementing and expanding our system of medicine by finding bridges to biomedicine and osteopathy; what I challenge is the need to negate Chinese medicine and its history.

 

Rory

 

I totally agree with you, Rory. And would add that without studying the Shang Han Lun, one's ability to understand and practice Chinese herbal medicine is greatly reduced.

 

I understand the need for both a rational/text based (i.e. 'classical') tradition, and the lineage of eclectic skills passed on by great practitioners in an oral tradition. They compliment each other. I support the efforts of Alon and others to keep this oral tradition alive, but not at the expense of the classical tradition. I also support development of biomedical skills, but, again, not at the expense of the classical tradition.

 

By the way, isn't it true that Dr. Hammer also argues that one DOESN " T need to study biomedicine to be an excellent practitioner of Chinese medicine? He said as much in an article I read by him.

 

 

[Guest guest]

, Rory Kerr <rorykerr@w...> wrote:

 

The study of the

> classics is part of the development of a well grounded and

> independent medical mind, and is one guard we have against placing

> too much reliance in self promoting authorities.

>

> Rory

 

Well put. I couldn't agree more.

 

[Guest guest]

I may not agree with everything he says. . . .. but I would really like to get access to his lecture notes or tapes (and I look forward to his pulse book). Can you help me here?>>>>Contact AAOM.

[Guest guest]

I have no argument with what you do Alon, which seems to me to be a very worthwhile attempt at complementing and expanding our system of medicine by finding bridges to biomedicine and osteopathy; what I challenge is the need to negate Chinese medicine and its history.

>>>I do not negate Chinese medicine. I only question everything around me including Chinese medicine. To me this is the only way to separate what is useful from dogma. Obviously CM has much to offer and a flexible toolbox. It is the assumption that if it is in the classics it is correct and relevant that I am questioning. I am also reacting from my own experience in which the most effective practitioners I saw in china used family systems that have to little with what we have learned as CM. According to Leon much of the classical pulse information is either wrong or just not apply to modern time (at least from what he said in the lecture). Another point he made is that although you may be able to tell that there is obstruction in the reproductive system you can not tell if it is cancer or other more benign blockage so modern diagnosis is imperative

alon

 

[Guest guest]

By the way, isn't it true that Dr. Hammer also argues that one DOESN"T need to study biomedicine to be an excellent practitioner of Chinese medicine? He said as much in an article I read by him.>>>>I do not know but I would assume that he fully supports studding the classics as I do. Ignorance is no solution. What he was saying is trust but verify.

alon