clinical discussions/was Digest Number 956

[Guest guest]

, " dragon90405 " <yulong@m...>

wrote:

 

I have always been taught

> and in all of my clinical work pretty

> much follow the dictum that " you must

> look at the patient " . This dimension

> is naturally not available in this

> forum, and so I don't use the forum

> as a medium for pursuing clinical

> ideas very much, as you notice from

> the content of my posts

 

I couldn't disagree more strongly with this statement. this

medium is quite well suited for the discussion of clinical cases.

Cases have long been presented in written form in both

traditional chinese and modern western medical literature.

Beause this medium is interactive, it is actually far superior for

this purpose than older styles of merely reading cases without

being able to comment or question. According to Chip Chace,

the study of written case literature is an important missing

element in American studies.

 

As for looking at the patient, that is not the necessarily the most

important part of the process of case analysis. It is essential,

but it also can be delegated to a competent student. In fact, this

is how clinical supervision functions in all forms of medical

education. Senior practitioners typically look at chart notes, lab

tests, etc and give guidance to the student. But they do not

ALWAYS see the patient. The process of analysing the data is

where most beginners fall short, moreso than in their inspection

of the tongue or gathering of other s/s. So whether one is sitting

in the conference room or reading a case online, this process of

assessment of data is one that takes place away from the

patient. Sure, if the data gathered is wrong, then it will all be for

naught. But we give each other the benefit of the doubt on that

accord. I don't have to see your patient to know that a

toothmarked tongue points to spleen vacuity.

 

[Guest guest]

 

 

It wasn't my intention to suggest that the

forum is not an appropriate place for

case discussion. I tried to make it clear

that I was describing a personal matter

and not a judgment of what others are

doing. I agree that presentation and

discussion of cases is an important

facet of medicine in general and

Chinese medicine in particular.

 

My personal approach to clinical

work makes this hard for me, for the reasons

that I described. I was only responding to

Doug's request that I provide detailed

answers to what various terms mean based

on clinical experiences.

 

Ken

[Guest guest]

Todd:

 

Your points are excellent. It seems an odd that someone supporting

that kind of scrupulous attention to medical terms would want to

preclude an actual discussion of case histories. Clinical

application is the litmus test for these ideas and terms. And this

forum offers the best exchange of those kinds of ideas.

 

Interestingly, while case histories are scattered through medical

writings, individually authored and and published case history

collections (yi'an) were an innovation of the late Ming. This

phenomenon is, according to Elisabeth Hsu, " generally explained to

testify to a shift in medical authority away from the heriditary

physicians who had previously been in the majority, to the scholar

doctors who increasingly populated the field. " The former had

claimed their authority and reputation through their family

tradition.

 

Chip's insight is very savvy.

 

 

Jim Ramholz

 

 

 

 

, " 1 " <@i...> wrote:

> I couldn't disagree more strongly with this statement. this

> medium is quite well suited for the discussion of clinical cases.

> Cases have long been presented in written form in both

> traditional chinese and modern western medical literature.

> Beause this medium is interactive, it is actually far superior for

> this purpose than older styles of merely reading cases without

> being able to comment or question. According to Chip Chace,

> the study of written case literature is an important missing

> element in American studies.

[Guest guest]

 

It is one thing to discuss cases, and another to give advice on

patients. I agree with Chip Chace that we need more case study

literature, and that it is one of the weakest links in our profession.

It is not that discussing clinical cases isn't important, it is just

that it is more difficult without actually seeing the patient, or

especially without adequate data on the patient. All of us still need a

lot of work in improving how we present case studies; I know I

certainly do.

 

 

On Saturday, April 6, 2002, at 05:55 PM, 1 wrote:

 

> I couldn't disagree more strongly with this statement.  this

> medium is quite well suited for the discussion of clinical cases. 

> Cases have long been presented in written form in both

> traditional chinese and modern western medical literature. 

> Beause this medium is interactive, it is actually far superior for

> this purpose than older styles of merely reading cases without

> being able to comment or question.  According to Chip Chace,

> the study of written case literature is an important missing

> element in American studies. 

[Guest guest]

I agree, Jim. The Yi' an literature is essential. Everyone should

check out Elizabeth Hsu's book, " Innovation in " .

 

 

On Saturday, April 6, 2002, at 07:06 PM, jramholz wrote:

 

:

>

> Your points are excellent. It seems an odd that someone supporting

> that kind of scrupulous attention to medical terms would want to

> preclude an actual discussion of case histories. Clinical

> application is the litmus test for these ideas and terms. And this

> forum offers the best exchange of those kinds of ideas.

>

> Interestingly, while case histories are scattered through medical

> writings, individually authored and and published case history

> collections (yi'an) were an innovation of the late Ming. This

> phenomenon is, according to Elisabeth Hsu, " generally explained to

> testify to a shift in medical authority away from the heriditary

> physicians who had previously been in the majority, to the scholar

> doctors who increasingly populated the field. " The former had

> claimed their authority and reputation through their family

> tradition.

>

> Chip's insight is very savvy.

>

>

> Jim Ramholz

>

>

>

>

> , " 1 " <@i...> wrote:

> > I couldn't disagree more strongly with this statement. this

> > medium is quite well suited for the discussion of clinical cases. 

> > Cases have long been presented in written form in both

> > traditional chinese and modern western medical literature. 

> > Beause this medium is interactive, it is actually far superior for

> > this purpose than older styles of merely reading cases without

> > being able to comment or question. According to Chip Chace,

> > the study of written case literature is an important missing

> > element in American studies. 

>

>

>

 

>

>

> Chinese 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]

, " " <

zrosenbe@s...> wrote:

>

> It is one thing to discuss cases, and another to give advice

on

> patients.

 

If someone gives me a diagnosis with justifying s/s and tells me

what herbs they chose, I see no difficulty in giving advice. for

example, someone tells me that their liver qi constrained bipolar

patient has been prescribed chai hu shu gan tang. I can say that

in my experience using he huan pi instead of chai hu often yields

better results because it calms and disperses, while chai hu

can sometimes seem to set off a manic episode. Or I can point

out that the dose of huang qi being used in the CFIDS patient is

much lower than I have used successfully in the past. Or being

presented with gathered data, I can help someone organize a

coherent diagnosis and treatment strategy. None of this

requires seeing the patient and it all serves a valuable purpose.

This list may be dominated by philosophical and theoretical

discussions, but the plurality of members have commented to

me privately that:

 

1. they think this forum is well suited for case discussion

 

2. they wish there were more case discussions

 

3. they are disappointed that more cases aren't discussed

 

I completely agree with these statements and do not want to see

any inhibition of this motivation. And I am surprised to hear this

from you, Zev, as you are one of the few people who has

engaged enthusiastically in case analysis on this list. You have

received praise for the help you have given and Bob Felt even

recently commented how much he enjoys seeing you or Bob

Flaws tackle a case in this way. I can honestly say that I have

learned the most in my career by getting comment on my

thought process from senior practitioners, even if they have

never seen the patient.

 

Now, I won't argue that the process is flawed if the data

gathering is flawed (garbage in, garbage out). But as a group of

professionals, I have to assume that members of this group are

doing that part right. Flaws has commented that many people

who ask him for advice have done a good job on dx and rx

selection, but err on dosage. This is exactly the type of thing that

yields well to advice on a list like this. Again, in my experience,

even students are pretty good at gathering data (assuming we

agree on certain definitions, that is, such as what constitutes a

white tongue coat). It is the assessment and planning where

they fall short.

 

[Guest guest]

 

 

My feelings or impressions of the engagement of case studies does not

contradict the fact that I or anyone else who engages in these cases

does so enthusiastically. I totally support the inclusion of even more

case studies that what we are doing now. And I totally support your

efforts in this direction, Todd.

 

At the same time, I think we can do even a better job at it. . . .and I

am concerned how we can do it without hurting feelings, as seemed to

have happened a few weeks ago with one of our list members. There

needs to be some filling out of the information given, and if my own

proddings to do so are not offensive, then, yes, I will be glad to do so

personally.

 

I used to be a clinical supervisor at PCOM, and one of the reasons I

stopped was the lack of time allowed to actually engage a case in the

depth it deserved. I found that most supervisors at the time, including

myself, were forced to make arbitrary decisions without accurate

information on the patient.

 

This is a source of my hesitation of giving advice, not just on this

list, but to other e-mail inquiries or phone calls from out of town. As

Bob Flaws as pointed out before on this list, the engagement with the

patient is largely a local, interactive event.

 

I feel a sense of responsibility to everyone I deal with, and I just

want to do the best job possible. But please, don't see my

feelings as negating one of the goals of CHA. I support you and the

list all the way.

 

 

On Sunday, April 7, 2002, at 12:44 PM, 1 wrote:

 

> I completely agree with these statements and do not want to see

> any inhibition of this motivation.  And I am surprised to hear this

> from you, Zev, as you are one of the few people who has

> engaged enthusiastically in case analysis on this list. 

[Guest guest]

 

 

I completely agree. In CM, there is a very adequate technical

terminology for describing patients verbally to coprofessionals.

That's one of the major reasons for the adoption of a technically

accurate standard translational terminology -- so we can share our

experiences and cross-reference them. The CM case history literature

in Chinese is huge. Besides comnpendia of case histories, some by

individual practitioners and others which are anthologies by groups

practitioners, most articles in CM journals include at least one

" representative " case history. Similarly, some of the better

contemporary clinical manuals also include respresentative case

histories at the back of every chapter.

 

In the last 18 months, we at BPP have made it SOP to try to include

such case histories at the end of as many chapters of our new books as

possible. We did this in our psych book, we have done this for every

chapter in our up-coming diabetes book (May-June release, we hope), I

have just finished several weeks of putting in case histories for the

new, combined edition of Path of Pregnancy (Jan '03), and we are

requiring such case histories of the authors of the cardiovascular and

nephrology books which are currently being written under contract for

us (2003 release).

 

Unfortunately, Chip's case history book was one of our worst sellers.

We never sold out of the first printing. Lately, we have even started

giving the book away as a perk or sales promotion. So, since there

does not yet seem to be a viable market for such case history

compendia, we are simply adding case histories to our

textbooks/clinical manuals. This way people don't have a choice. Like

an MS product, they're now " bundled " with the rest of the " software. "

 

In our Blue Poppy Institute Gynecology and Pediatrics Certification

Programs, written case histories are part of the required homework,

and students in these programs have told us two things about this

requirement. First, this is typically the hardest part of the

homework. Students find it very hard to write cogent CM case

histories, in large part (IMO), due to the fact that they have not

read large numbers of CM case histories. If one reads large numbers of

these, one sees that this is a genre of literature with certain norms

and forms. Once one has pickled themself in those norms and forms, it

is not very difficult to write a similar case history from one's own

files. (When I was in college, I " pickled " myself in the " true

confessions " genre just to see if I could reproduce it and get

published. An interesting writing exercise.)

 

Secondly and more importantly, many students have told us that writing

these case histories and the feedback they received on them was one of

the most important learning aspects of these programs. Knowing what is

and is not cogent in a professional CM case history is not easy until

or unless you have read lots and lots of these. However, if you can

weed through a welter of information to get to the core important

signs and symptoms, then, not only can you write a valuable case

history which is easily accessible by one's peers, but you can also

come to a pattern discrimination more easily and accurately in your

personal clinical practice. At least that is our and our students'

experience.

 

Bob

 

, " 1 " <@i...> wrote:

> , " dragon90405 " <yulong@m...>

> wrote:

>

> I have always been taught

> > and in all of my clinical work pretty

> > much follow the dictum that " you must

> > look at the patient " . This dimension

> > is naturally not available in this

> > forum, and so I don't use the forum

> > as a medium for pursuing clinical

> > ideas very much, as you notice from

> > the content of my posts

>

> I couldn't disagree more strongly with this statement. this

> medium is quite well suited for the discussion of clinical cases.

> Cases have long been presented in written form in both

> traditional chinese and modern western medical literature.

> Beause this medium is interactive, it is actually far superior for

> this purpose than older styles of merely reading cases without

> being able to comment or question. According to Chip Chace,

> the study of written case literature is an important missing

> element in American studies.

>

> As for looking at the patient, that is not the necessarily the most

> important part of the process of case analysis. It is essential,

> but it also can be delegated to a competent student. In fact, this

> is how clinical supervision functions in all forms of medical

> education. Senior practitioners typically look at chart notes, lab

> tests, etc and give guidance to the student. But they do not

> ALWAYS see the patient. The process of analysing the data is

> where most beginners fall short, moreso than in their inspection

> of the tongue or gathering of other s/s. So whether one is sitting

> in the conference room or reading a case online, this process of

> assessment of data is one that takes place away from the

> patient. Sure, if the data gathered is wrong, then it will all be

for

> naught. But we give each other the benefit of the doubt on that

> accord. I don't have to see your patient to know that a

> toothmarked tongue points to spleen vacuity.

>