WHy Talk Pulses? No interexaminer reliabiity.

[Guest guest]

In a message dated 8/28/2002 10:01:31 PM Central Standard Time, alonmarcus writes:

 

 

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

 

 

If there are no studies, and if there is no way it could happen, then why are people in this group asking those who present cases to say anything about the pules?

[Guest guest]

Rory - the IRR findings were also weak for the other diagnostic methods. Calibration is the issue. The IRR goes way up with a well callibrated group. Doing a proper study on this topic will require funding.

 

Will

 

Why do you think pulse requires this sort of study, more so than other competencies such as tongue or inquiry, etc, before we should ask list members to report on their findings?

 

 

What would such a study do to reassure us as to the competence of any one practitioner reporting on this list?

[Guest guest]

In a message dated 8/29/2002 7:05:22 AM Central Standard Time, rorykerr writes:

 

 

Why do you think pulse requires this sort of study, more so than other competencies such as tongue or inquiry, etc, before we should ask list members to report on their findings?

 

 

What would such a study do to reassure us as to the competence of any one practitioner reporting on this list?

 

 

 

 

I think that the interexaminer reliability of "inquiry" as a modality would be very high. Every examiner would get the same answers to his question: "Do you sleep well."

 

Tongue diagnosis should also have high interexaminaer reliability also, since we are asking people generally to identify colors. I think most everyone could distinguish a white coat from a yellow one.

 

These two interexaminer studies might make a good practice experiment for some senior at a college doing his course on research methods.

 

But the problem with pulse diagnosis I think is more profound. There are about 60 "qualities" or parameters which practitioners are supposed to be able to identify. These qualities are perceived kinesthetically, and our language is markedly visual. If we find that it isn't possible to have two people call the same thing by the same name, then it would seem that not one can even discuss pulses.

 

So the question was not about the diagnostic abilities of various group members. It was about whether or not this discussion is possible in any sense.

 

Guy Porter

DrGRPorter

[Guest guest]

At 2:10 AM -0400 8/29/02,

drgrporter wrote:

If there are no studies, and if there is no way it

could happen, then why are people in this group asking those who

present cases to say anything about the pules?

--

 

Why do you think pulse requires this sort of study, more so than

other competencies such as tongue or inquiry, etc, before we should

ask list members to report on their findings?

 

What would such a study do to reassure us as to the competence of

any one practitioner reporting on this list?

 

Rory

--

[Guest guest]

, Rory Kerr <rorykerr@w...>

wrote:

 

>

> Why do you think pulse requires this sort of study, more so

than

> other competencies such as tongue or inquiry, etc, before we

should

> ask list members to report on their findings?

 

I think we should study the diagnostic process as a whole for

interrater reliability. In other words, presented with a patient, will

people come up with the same diagnosis? Not unless they all

have identical training. It would be a way to assess one's

training, at least. But it will never satisfy me that any report is

valid or that I even have the same mental image of say, the wiry

pulse. In fact, experience tells me I could very likely disagree

with just about anyone when the patient is before me. At least

with inquiry, we can feel confident that the practitioner reports

what the patient said, even if the interview was less than skillful.

And it could be recorded (which actually might not be a bad idea

for interns .... hmmmm, but I digress). tongues could be

photographed. But pulse, there is just no way to document that

for others to assess indepedently. So I guess all we have is our

word and thus the need to demonstrate competency is higher.

Now, of course, since we are not recording interviews and

photographing tongues, I agree we need to be concerned about

the reliability of every aspect of dx that is reported to us at this

time.

 

[Guest guest]

Why do you think pulse requires this sort of study, more so than other competencies such as tongue or inquiry, etc, before we should ask list members to report on their findings?

>>>I think they all do. And has my Kaiser study showed no such ability was shown within 9 practitioners 5 of which are Chinese trained. By the way the Chinese trained did not do any better than the US trained

Alon

[Guest guest]

Tongue diagnosis should also have high interexaminaer reliability also, since we are asking people generally to identify colors. I think most everyone could distinguish a white coat from a yellow one.>>>>Well like I have said our study did not show any interexaminaer reliability at all

Alon

[Guest guest]

, WMorris116@A... wrote:

 

> Calibration is the issue. The IRR goes way up with a well

callibrated group.

 

Indeed. Do you also think it would be better for master's level

students to be so calibrated in their training. After an early

survey of styles, students would work closely with teachers who

are calibrated to a style. An entire college could be calibrated to

a single scale or there could be options within a school. but

otherwise, it is like that damn scale I have to zero every time I

weigh a formula because I don't know who mucked around with

the settings since the last time I was in the pharmacy. but if

there is any value in chinese diagnostics, there has to be

reliability. calibration is the key to styles like hara diagnosis, so

this is not some covert attempt to impose one set of TCM

standards on the profession. I spend a lot of time in clinic

explaining why people disagree with each other's diagnosis, but

ultimately, there is no logic in the differences, just style. This is

an important consideration when recruiting faculty from china. A

great scholar-doctor is just a wrench in the works if the rest of

the faculty does not agree with his methods. As more of a

clinician than a classroom teacher, I am strongly biased by my

need to have efficient confident students who speak the same

clinical language. Well, one can dream.

 

[Guest guest]

Not unless they all have identical training.

>>>In our study their were two class mates from shang hai and they did not agree at all on pulses, tongue, and on diagnosis other than K Yin Def for hot flashes (which is almost like saying menopause in TCM). No agreement of any of the secondary diagnosis was seen. Some where LOWER than chance.

Alon

[Guest guest]

In other words, presented with a patient, will

people come up with the same diagnosis?

 

 

This reminds me of a teacher I had in school who almost always had a

diagnosis of " phlegm, damp, mucus " with an occasional liver qi

stagnation thrown in. But his treatment plan was almost always

different. So in these studies of IRR, it would be interesting to see

what the treatment plans are (both points and herbs) and see if there

was any correlation between differently trained practitioners giving

different diagnoses, but perhaps prescribing similar treatments. Has

anyone had any experience with this?

 

Colleen

[Guest guest]

Todd

 

As a clinician, this is not a need I share. I am curious if a well designed needs assessment would substantiate either of our positions. Or - if it would reflect on a larger scale the two points of view as being discretely valid.

 

Will

 

As more of a clinician than a classroom teacher, I am strongly biased by my need to have efficient confident students who speak the same clinical language. Well, one can dream.

[Guest guest]

That was my experience too - Will

 

Well like I have said our study did not show any interexaminaer reliability at all

[Guest guest]

it would be interesting to seewhat the treatment plans are (both points and herbs) and see if therewas any correlation between differently trained practitioners givingdifferent diagnoses, but perhaps prescribing similar treatments

>>>>We had an unofficial treatment proposals from some of the participants that was not part of the study, but was going to be used for a possible follow-up study. There was little agreement as to herbs

Alon

[Guest guest]

Todd -

 

Yes - I should have stated 'as a teaching clinician.'

 

Our school has TCM as a foundation. We also have a commitment to supporting lineage styles as well. This can include Yuen, Shen, Tong, or even Worsely. These are on a survey course basis so students are familiar with the some of the postgraduate life long learning possibilities.

The students and supervisors must find common ground for communication. It is up to both to create meaningful clinical interactions.

We have a 40 hour Worsely course and people who are interested in that style can get supervision from me since I have studied and used it in TCM context it works for them. Also - people can study neoclassical pulse styles or Shen/Hammer pulse styles with me or others here. In addition, there are teachers and students who regularly study with Yuen and the students often bring the material forward in clinic. My rule is they have to withstand my questioning of their thought process and rationale. They cannot give treatment merely because they heard it in a seminar.

 

There are complications with administration of inclusive policy - but it is worth it to me. I can't expect faculty who are fresh off the boat to deliver eclectic stuff and neither can the student. Students are asked to discover the strengths of the supervisor, avoid trying to impress them with information outside their experience, and get what that supervisor brings to the table.

 

Will

 

You know I am referring to my role as a supervisor in the teaching clinic, not my private practice? Just out of curiosity, how do you work with students who have not been trained in the fundamentals of the method you use? For example, to work with someone who is worsley trained, I might as well be with someone who speaks swahili.

[Guest guest]

, WMorris116@A... wrote:

 

>

> As a clinician, this is not a need I share.

 

Will

 

You know I am referring to my role as a supervisor in the

teaching clinic, not my private practice? Just out of curiosity, how

do you work with students who have not been trained in the

fundamentals of the method you use? For example, to work with

someone who is worsley trained, I might as well be with

someone who speaks swahili.

 

[Guest guest]

As I have stated many times, I feel I get better results with this type of eclecticism.

>>>>>I have found in my practice that is about 60% orthopedics, eclecticism is a must to get the kind of clinical outcomes I like

Alon

[Guest guest]

, WMorris116@A... wrote:

I am curious if a well designed

> needs assessment would substantiate either of our positions.

Or - if it would

> reflect on a larger scale the two points of view as being

discretely valid.

 

My observation would be that a good experienced eclectic

practitioner gets similar results to one who practices more

narrowly. However, at the early stages, I find students who focus

more narrowly do much better in clinic than those who are faced

with too many choices. Within chinese medicine, I am

somewhat narrow in my teaching because of this observation.

In my private practice, my approach is more eclectic,

encompassing family lineage styles I have learned, japanese

acupuncture, as well as naturopathy and ayurveda. As I have

stated many times, I feel I get better results with this type of

eclecticism. However, for a few years, my studies were

exclusively on chinese herbal medicine and TCM. this is my

foundation from which I pivot into my personal medical archive.

It took me a long time to be comfortable with methods for which I

have less formal training. Those have all been learned by study

and apprenticeship. I find very few students can reach a high

degree of competency in more than one of these styles during a

4 year program. I don't know how we would assess this.

students from 2 quite eclectic schools, emperor's and PCOM, do

quite well on the largely TCM CA boards. In fact, they get get

higher scores on the average than some (but not all) of the

strictly TCM schools. I am not sure that means anything, though.

What would interest me would be comparing clinical results of

differently trained students).