Complexity in Pulses: interexaminer reliabiity?

[Guest guest]

In a message dated 8/26/2002 10:23:05 AM Central Standard Time, jramholz writes:

 

 

This is why we do pulse diagnosis using three depths---and why we

are always talking in threefold terms. Any less rigorous model of

diagnosis, like 8-Principles, can only be descriptive of homeostasis

at best. I find it ironic that the Chinese would marginalize pulse

diagnosis and 5-Phases in their attempt to standardize CM and make

it more like Western medicine,

 

 

Are there any studies, in Chinese or English, addressing the interexaminer reliability of pulse diagnosis? How many such studies are there and what kind of statistical analysis was used in them? Perhaps those attempting to standardize the field realized that they had no hope at that time of being able to "standardize" something which seems so subjective.

 

I don't mean to insult anyone by this, and realize it might be a touchy subject. So no disrespect is meant. But in order to call pulse diagnosis objective and to maintain that it can detect so many things based on so many variables, a lot of groundwork would need to be done. Has it been done?

 

That would be the most fundamental study to do if one were to try to impose rigor in a diagnostic paradigm that relied so heavily on them.

 

Guy Porter

DrGRPorter

 

DrGRPorter

[Guest guest]

, drgrporter@a... wrote:

> Are there any studies, in Chinese or English, addressing the

interexaminer reliability of pulse diagnosis? How many such studies

are there and what kind of statistical analysis was used in them?

Perhaps those attempting to standardize the field realized that they

had no hope at that time of being able to " standardize " something

which seems so subjective.

> But in order to call pulse diagnosis objective and to maintain

that it can detect so many things based on so many variables, a lot

of groundwork would need to be done. Has it been done?

 

Although you hear about the development of a pulse machine every so

often, I doubt if technology has been successful in reading much in

the pulses. Because technology has been never able to approach the

sensitivity of the human touch or the complexity of the brain, I

doubt if there is any hope in making pulse diagnosis more objective,

and moving it from the catagory of art to the category of science.

Unlike, say, measuring the alkaloid content and effect of an

individual herb, there is no way to standardize the human touch or

the neurophysiology that connects it to theory in the mind. Two

people playing the identical musical sheet music, even when

attempting to play together, aren't completely similar.

 

No studies have been done that I know of. I suspect the problem is

additionally complicated by the fact that very few people ever learn

pulse diagnosis to any significant extent. Most TCM schools only

teach a little bit of Li Shi-zhen, a very basic text. Outside of the

Shen/Hammer system and my own Dong Han system, I haven't heard of

any extensive interest in teaching pulses.

 

So, we have two complex living systems---the patient and the

practitioner---interacting and creating a larger, more complex

system that, like its two component systems, can't be reduced to

linear equations. Offhand, I suspect clinical efficacy in diganosis

is the only criteria available.

 

 

Jim Ramholz

[Guest guest]

jramholz wrote:

 

> No studies have been done that I know of. I suspect the problem is

> additionally complicated by the fact that very few people ever learn

> pulse diagnosis to any significant extent.

 

We tried to get an interater reliability study going recently at

Emperor's. The raters were mostly myself with my scanty ECTOM pulse

training and Will with his years of exposure to a variety of other pulse

reading modalities.

 

We could barely agree on where to place the fingers, let alone the

quality of the pulse. Ultimately, we found that we could easily agree

on his " eight extra pulses " , but we never persued this any further...

 

--

Al Stone L.Ac.

<AlStone

http://www.BeyondWellBeing.com

 

Pain is inevitable, suffering is optional.

[Guest guest]

, Al Stone <alstone@b...> wrote:

> We could barely agree on where to place the fingers, let alone the

> quality of the pulse. Ultimately, we found that we could easily

agree on his " eight extra pulses " , but we never persued this any

further...

 

Al:

 

Agreement was never a problem in the Dong Han system due, in part,

to the relative isolation of our study. It is a Korean system and

there were no distractions from other schools or teachers in the

80s. Concepts outside of our system were either quickly absorbed

(some Japanese acupuncture points and needling skills) or ignored

(Japanese hara diagnosis). Quite literally, everything in the Dong

Han system is based on or refers back to the pulses; so the few of

us who attained any ability easily agreed on findings---even, for

the few students remaining, years later. I had to study TCM on my

own to take the NCCA board test in 1985.

 

Eight Extra Pulses could be a good beginning to consensus. Are you

familiar with the Shen/Hammer material? I find myself using some of

its ideas, from time to time, in clinic. I point out a feature in

the pulse (for example, this weekend it was about blood sugar) using

the Dong Han system, and then point out the Shen/Hammer finding if I

know it and see it.

 

Why didn't you pursue this study further?

 

 

Jim Ramholz

[Guest guest]

Jim,

 

This study required that Will Morris, Terry Oleson and myself get

together to work on this, and we all simply ran short of time, at least

that was the issue for me.

 

I do admit that these 8 extras pulses is a really easy system to learn

and is very easy to communicate and agree on. Its more about the

location of the pulse and the vessle than wave form qualities, at least

as I have been exposed to it. Will may be a better person to describe

these things.

 

The 8 extras pulses showed the most potential for interexaminer

reliabiity. As for the therapeutic outcomes of the treatments that this

diagnosis style indicates, I haven't a clue... The Dai Mai pulse

(excessive and large in the middle positions of both arms) looks a lot

like the Liver/Spleen disharmony as I was taught by the guy who also

teaches a two day seminar on the 8 extras (Yang, Tiende). However,

Beijing trained Dr. Yang seems not to be familiar with the " Eight Extras

pulses "

 

-al.

 

jramholz wrote:

>

> , Al Stone <alstone@b...> wrote:

> > We could barely agree on where to place the fingers, let alone the

> > quality of the pulse. Ultimately, we found that we could easily

> agree on his " eight extra pulses " , but we never persued this any

> further...

>

> Al:

>

> Agreement was never a problem in the Dong Han system due, in part,

> to the relative isolation of our study. It is a Korean system and

> there were no distractions from other schools or teachers in the

> 80s. Concepts outside of our system were either quickly absorbed

> (some Japanese acupuncture points and needling skills) or ignored

> (Japanese hara diagnosis). Quite literally, everything in the Dong

> Han system is based on or refers back to the pulses; so the few of

> us who attained any ability easily agreed on findings---even, for

> the few students remaining, years later. I had to study TCM on my

> own to take the NCCA board test in 1985.

>

> Eight Extra Pulses could be a good beginning to consensus. Are you

> familiar with the Shen/Hammer material? I find myself using some of

> its ideas, from time to time, in clinic. I point out a feature in

> the pulse (for example, this weekend it was about blood sugar) using

> the Dong Han system, and then point out the Shen/Hammer finding if I

> know it and see it.

>

> Why didn't you pursue this study further?

>

> Jim Ramholz

>

>

> 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]

, Al Stone <alstone@b...> wrote:

> The 8 extras pulses showed the most potential for interexaminer

> reliabiity. As for the therapeutic outcomes of the treatments that

this diagnosis style indicates, I haven't a clue... The Dai Mai

pulse (excessive and large in the middle positions of both arms)

looks a lot like the Liver/Spleen disharmony as I was taught by the

guy who also teaches a two day seminar on the 8 extras (Yang,

Tiende). However, Beijing trained Dr. Yang seems not to be familiar

with the " Eight Extras pulses. "

 

 

Al:

 

None of our Chinese teachers here seem very familiar with pulse

diagnosis either. It seems to be a marginalized method of diagnosis

compared to the scientific methods; and they have other specialties

or family styles to draw upon.

 

In the Dong Han system, we are familiar with but seldom make use of

the 8-Extra Pulses or 8-Extra Meridian treatment styles. My

interested in 8-Extra meridian treatments has increased somewhat

since hearing Miki Shima prefer it for cancer treatments over other

acupuncture methods.

 

From what I've observed in other practitioners' treatments of

patients using 8-Extra acupuncture---and from my own experience

receiving several treatments---is that it works better at the

meridian and muscle channel depths and not that well at the organ

depth. The literature says it moves the jing qi, but I'm not

completely convinced. Our Dong Han acupuncture treatment style for

cancer, as with many other problems, combines 5-Phases and 6-Qi (5-

Phase transactions along with the movements in the regular channels

and divergent channels).

 

It's a great luxury to be able to work together with people of that

caliber. Do you think that you guys will make time in the future to

continue this line of investigation?

 

 

Jim Ramholz

[Guest guest]

Al -

 

I think we were able to arrive at a higher level of reliability because the eight extra vessel patterns are a morphological method of diagnosis that takes into account the shape and distribution of volume from position to position. I find pulse features related to shape far easier to grasp resulting in more consistent findings from practitioner to practitioner. The patterns we used are available at acupuncturetoday.com for those who are interested. The descriptions are an interpretation of the source text.

Wang shuhe describes the patterns as dynamic, that is, they vibrate side to side for the yin qiao, yang qiao, and dai mai. However, my clinical experience suggests that shape is sufficient to ask for confirming signs and symptoms. When it is shape that is uneven, use of the master point will quickly cause an even distribution in quick order. Lack of response suggests the involvement of other vessels or movements of qi such as the night-time wei qi movement along the five element controlling cycle.

 

It is far more difficult to identify temporal phenomena within the wave, this is an area where inter-rater realiability falls apart. In addition, there is very little discussion on the topic in the standardized literature such as CAM - flooding pulses are the extent. Shen and Hammer discuss wave analysis in part - usually assigning fixed interpretations. The Mai Jing, Nei Jing, and Nan Jing all give whole models for analysis of this more ephemeral aspect of pulse diagnosis.

 

Will

 

 

We could barely agree on where to place the fingers, let alone the

quality of the pulse. Ultimately, we found that we could easily agree

on his "eight extra pulses", but we never persued this any further...

[Guest guest]

I am not so sure that there is any (traditional) literature that says

that the eight extraordinary vessels move the jing qi. What text(s) are

you referring to?

 

 

On Monday, August 26, 2002, at 05:24 PM, jramholz wrote:

 

> From what I've observed in other practitioners' treatments of

> patients using 8-Extra acupuncture---and from my own experience

> receiving several treatments---is that it works better at the

> meridian and muscle channel depths and not that well at the organ

> depth. The literature says it moves the jing qi, but I'm not

> completely convinced.

[Guest guest]

In , " " <zrosenbe@s...> wrote:

> I am not so sure that there is any (traditional) literature that

says that the eight extraordinary vessels move the jing qi. What text

(s) are you referring to?

 

 

Z'ev:

 

I looked, but couldn't find any text either. It was something I

thought I remembered hearing or reading a long time ago---perhaps

something said in a lecture or in passing---that didn't sound or

feel quite correct and didn't jive with any of my experience. That's

why I qualified it.

 

 

Jim Ramholz

[Guest guest]

Are there any studies, in Chinese or English, addressing the interexaminer reliability of pulse diagnosis? How many such studies are there and what kind of statistical analysis was used in them? Perhaps those attempting to standardize the field realized that they had no hope at that time of being able to "standardize" something which seems so subjective. >>>>>>>

O no statistical analysis. There is no way it would ever happen

Alon

[Guest guest]

No studies have been done that I know of. I suspect the problem is additionally complicated by the fact that very few people ever learn pulse diagnosis to any significant extent

>>>The science of it should be studies perhaps using the teachers

Alon

[Guest guest]

We could barely agree on where to place the fingers, let alone thequality of the pulse. Ultimately, we found that we could easily agreeon his "eight extra pulses", but we never persued this any further...>>>>Did the eight extra pulses done in controlled situation. What type of agreement did you get? i.e. how much above random etc

Alon

[Guest guest]

so the few of us who attained any ability easily agreed on findings---

>>>This needs to be shown with independent verifiers.

Alon

[Guest guest]

, " Alon Marcus " <

alonmarcus@w...> wrote:

> so the few of

> us who attained any ability easily agreed on findings---

> >>>This needs to be shown with independent verifiers.

 

 

and even if verified independently, it still only demonstrates that

those with the same teacher can learn to agree. In fact, at

PCOM, I find the students have a high rate of agreement

amongst themselves. why? because a single chinese

professor dominates the training in pulse. this would be a good

thing except that he does not supervise interns and those of us

that do were not trained by him. Therein lies the dilemma. Why

does pulse assessment vary so much BETWEEN teachers? I

think perhaps history may shed some light on this.

 

The pulse was used in ancient greece, tibet, india, all of

southeast asia and the arab lands. so docs all over the place

were feeling pulses and correlating them with diseases and

patterns. But between cultures, there were very different ways of

describing pulses. Ayurveda mainly uses images of animal

movements as pulse metaphors. In china, there were books

talking about the pulse that got pretty wide distribution a very

long time ago. So imagine you are Dr. Li in the sichuan

province. Close to tibet, the local medical tradition has long

been influenced by buddhist travelers from over the himalayas.

It's about 1000 AD and you have copies of the mai jing and nan

jing. You've only met a few other literate doctors in your 30 years

of practice because folks who can read are pretty rare in your

day. So when you read the mai jing, your interpretation is

defined by very narrow influences.

 

Consider another doctor on the border of vietnam or Korea at a

different time in history. Again isolated with different influences.

No wonder there is so little agreement amongst pulse teachers.

And that's the strange thing about TCM. While those who deride

it consider it to be monolithic and overly standardized, it is

actually just the thin wrapping for a 100 different lineal traditions.

But the question must be begged. Even if we can train interrater

reliability, what does it mean that we could produce ten groups

of pulsetakers who agree within the group but not between

them? Well, I suppose physicans at John Hopkins may have

different criteria for assessing cancer than sloan kettering does.

that is why one seeks 2nd opinions for serious conditions. so

even western physicians will look at the same evidence and see

different things.

 

Is it any different with us? not that this gives me much comfort, by

the way. But it does underscore something I have often said.

you are better off learning one school of thought very deeply than

many superficially. Because to achieve interrater reliability in a

school of thought, one has to ignore alternate interpretations of

data. For example, one may diagnose lung vacuity in some

meridian acupuncture styles by merely identifying a weakness in

the deep cun position on the right wrist. But when this is

reported to me, only very occasionally does it coincide with

sufficient signs and symptoms to make a TCM lung vacuity dx.

So you really can't mix and match this way.

 

The rebuttal I often hear is that if one knows many styles, one

has more clinical options. Yet unless one knows something

very deeply, what is the basis of one's choices? The answer I

often hear. Intuition. That scares me because I think intuition is

nothing more than the ability to process and access one's

memory in a nonlinear fashion. It is not some mystical power

that transcends the need for learning. So your " intuition " is

limited by what you have learned and experienced. If you know

nothing deeply, then your intution will likewise be shallow.

 

I need to add that I actually have a lot of admiration for those who

have focused themselves narrowly on a particular style that

emphasizes pulse as the key diagnostic. But I think there are

plenty of examples of chinese physicians who did not put such

prominence in the pulse. the value of any bonafide style is in the

depth to which one approaches it. when one succeeds in one

style and not another, that says little about the styles and

everything about the person. for example, if one's intellectual

powers are great, but palpatory skills poor, that will affect what

works for you and vice-versa. I think its vital we remember that

(and I did not mean to imply that pulse afficionados are not

intellectual; obviously that is not true, if this list is an example.

but many anti-intellectuals are drawn to styles that eschew

logical thought. that is also undeniable).

 

[Guest guest]

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

Yet unless one knows something very deeply, what is the basis of

one's choices? The answer I often hear. Intuition. That scares me

because I think intuition is nothing more than the ability to

process and access one's memory in a nonlinear fashion. It is not

some mystical power that transcends the need for learning. So

your " intuition " is limited by what you have learned and

experienced. If you know nothing deeply, then your intution will

likewise be shallow.

 

:

 

Excellent point. I always warn my students in clinic and in seminar

that I never want to hear the word " intuition " coming from their

lips. It is too often a cover for intellectual laziness.

 

 

Jim Ramholz

[Guest guest]

and even if verified independently, it still only demonstrates that those with the same teacher can learn to agree. In fact, at PCOM, I find the students have a high rate of agreement amongst themselves. why? because a single chinese professor dominates the training in pulse. this would be a good thing except that he does not supervise interns and those of us that do were not trained by him. Therein lies the dilemma. Why does pulse assessment vary so much BETWEEN teachers? I think perhaps history may shed some light on this.>>>>Todd how many qualities are we talking about. Is it the two wiry and slippery?

Alon

[Guest guest]

different time in history. Again isolated with different influences. No wonder there is so little agreement amongst pulse teachers. >>>Todd my question is, is it possible humanly. From all the study of physical medicine diagnosis (which i have done both in the TCM and some western traditions) I have come to the conclusion that it is very rare to see such reliability even when practioners are trained in the same methods. That is why I also feel modern diagnostic methods are so important to verify outcomes and diagnosis

Alon

[Guest guest]

, " Alon Marcus " <alonmarcus@w...>

From all the study of physical medicine diagnosis (which i have done

both in the TCM and some western traditions) I have come to the

conclusion that it is very rare to see such reliability even when

practioners are trained in the same methods. That is why I also feel

modern diagnostic methods are so important to verify outcomes and

diagnosis.

 

 

Alon:

 

Isn't the reliability of Western diagnosis often in doubt? How many

times does a problem persist and there is no diagnosible cause by

WM? And how often does WM change it's dignostic positions? Western

doctors were against washing their hands and anesthesia when they

first introduced into practice. And today the big 180-turnaround on

dietary standards because what was accepted earlier didn't prevent

heart disease.

 

Except in emergency and life-threatening situations has WM faired

that much better than chance?

 

 

Jim Ramholz

[Guest guest]

Isn't the reliability of Western diagnosis often in doubt?

>>>When relied on physical examination always in doubt.

alon

[Guest guest]

How many times does a problem persist and there is no diagnosible cause by WM

>>>That is a different question than reliability of history and physical alone

Alon

[Guest guest]

And how often does WM change it's dignostic positions? Western doctors were against washing their hands and anesthesia when they first introduced into practice. And today the big 180-turnaround on dietary standards because what was accepted earlier didn't prevent heart disease. >>>You have no argument from me about the short coming of WM. However, that does not make the human hand more sensitive and consistent. I think one can use ones palpation skills very effectively in the clinic however, this is a complex question and when controlling, and assessing for multiple factors, physical skills, and clinical outcome, physical type medicine often falls short in statistical methods. I think this is something we need to address as a profession. And it may, or not, require a change in the way we practice TCM.

Alon

[Guest guest]

Some good points, Todd. However, again the Mai Jing has principles

that could be applied more universally than the limitations of one

author. That is why it is a jing, or a classic.

 

The Chinese shared with Tibet and India a certain intimacy with the

natural world. That is why there are natural metaphors in all three

systems. The Tibetans talk about a pulse quality like " a cow drooling

into the wind " , the Chinese about a pulse like " linden leaves floating

in a breeze " for the lung quality pulse. They are qualities that were

easily shared by people living in a natural environment.

 

Our modern medical discourse is dominated by technological metaphors,

therefore it is difficult for us to understand or communicate some of

these qualities. I myself think we need to learn how to relate to

these qualities by immersing ourselves in nature as much as possible,

by going to mountains, gardening, eating natural foods, etc. Learning

to listen to waves rolling in on the beach, birds circling overhead.

To some this may seem silly, but it is very important.

 

The Nan Jing uses many of these natural metaphors in describing pulses.

 

 

On Thursday, August 29, 2002, at 07:37 AM, 1 wrote:

 

> The pulse was used in ancient greece, tibet, india, all of

> southeast asia and the arab lands.  so docs all over the place

> were feeling pulses and correlating them with diseases and

> patterns.  But between cultures, there were very different ways of

> describing pulses.  Ayurveda mainly uses images of animal

> movements as pulse metaphors.  In china, there were books

> talking about the pulse that got pretty wide distribution a very

> long time ago.  So imagine you are Dr. Li in the sichuan

> province.  Close to tibet, the local medical tradition has long

> been influenced by buddhist travelers from over the himalayas. 

> It's about 1000 AD and you have copies of the mai jing and nan

> jing.  You've only met a few other literate doctors in your 30 years

> of practice because folks who can read are pretty rare in your

> day.  So when you read the mai jing, your interpretation is

> defined by very narrow influences. 

[Guest guest]

By the time we were playing around with the 8 extra pulses, we'd spent a

lot of time trying to come up with a common ground for pulse diagnosis,

in fact I think we'd been working on this for about a year.

 

We found that one's training can help a lot. For instance, Doug and I,

who've had similar training tended to agree more, whereas Will and I

agreed much less.

 

When Will and I narrowed down the 28 pulse options to just eight, we

found it much easier to do, but we never actually tested this on

patients. We just tried it on a few people who happened to be standing

around at the time.

 

> Alon Marcus wrote:

>

> We could barely agree on where to place the fingers, let alone the

> quality of the pulse. Ultimately, we found that we could easily agree

> on his " eight extra pulses " , but we never persued this any further...

> >>>>Did the eight extra pulses done in controlled situation. What type

> of agreement did you get? i.e. how much above random etc

> Alon

 

--

Al Stone L.Ac.

<AlStone

http://www.BeyondWellBeing.com

 

Pain is inevitable, suffering is optional.

[Guest guest]

Z'ev,

 

The pulse diagnosis metaphors found in the Nan Jing are primarily extrapolated from the Nei Jing.

 

Will

 

The Nan Jing uses many of these natural metaphors in describing pulses.

[Guest guest]

OK - I see ....

 

I just use the Schience and Technology Press version with the characteres and look them up or work with native Chinese speakers and iron the concepts out.

 

Will

 

This is just a text I have more familiarity with. When Unschuld comes out with his Nei Jing, I'm sure I'll spend lots of time with it. The Chinese Nei Jing's I have are too difficult for me, and the English translations (I have seven of them) are all unreliable.