self selection

[Guest guest]

I started to write this a month ago after I heard a news report on the

latest study on hormone replacement therapy (HRT). Then I thought it was

irrelevant and deleted it. Now it seems relevant again. As most of you

know, a well designed controlled double blind trial showed that a drug

commonly prescribed to menopausal women containing both estrogen and

progestin conferred no long term benefit to the bones and the heart and

was even slightly dangerous in regard to some types of cancer.

Nevertheless, thousands of women and their doctors will still swear by the

drug. And earlier studies showed it was helpful. So what gives?

 

Well, the earlier studies were extremely large (which is good), but also

extremely flawed in that they did not factor out other variables in the

etiology of osteoporosis and heart disease. It turned out that when one

factored in diet, exercise, family history, etc., those other factors may

have played as much significance, if not more than the drugs. What they

had missed is that the same women who were aware of the purported benefits

of HRT were also more likely to eat well. exercise, not smoke, etc. So

while the drug relieved nightsweats and hot flashes effectively, it has

done little else of value.

 

How does this relate to TCM? While we get plenty of patients who have

terrible eating and exercise habits, I think the population that seeks out

acupuncture in most western countries are relatively affluent, educated

and interested in changing their lives to improve their health. Thus they

are what statisticians call a self selected population. Like the women

who got on the HRT bandwagon early, this self selected group is often

involved in many " healthful " activities. Numerous studies in many fields

have shown over and over again, one cannot make generalizations from a

self selected group to the population at large. And because self selected

patients that receive acupuncture do many things to improve their health,

one can never be sure what has caused the crucial change in any given

person. When I hear a patient has improved, I always assume it is the

herbs. Others of my colleagues immediately think it was the acupuncture.

Patients tell me that they had a breakthrough with their psychologist and

that's what triggered the change. Our biases make us assume we

facilitated the change, when our role may have been coincidence in any

given case.

 

As an aside, I wonder whether anyone can confirm whether the clinical

audits that are reported in many chinese journals typically would be

comprised of such a self selected group. It is my understanding that

patients make their own choice in China to seek out western or TCM care.

When these audits are from self selected patients, that would partially

explain the extremely high success rates often reported. If we can't rely

on our isolated subjective experiences and perhaps not even much of the

modern chinese research, where do we put our " faith " . I think the only

choice we have is to follow the actual tradition as it is recorded in the

premodern literature. With regard to form and dosage, there is a wide

range in the premodern formularies, but we can identify a low end and

high end. the low end is about equivalent to what are used in modern

taiwan and japan and the high end is closer to modern PRC style. As long

as we stay in this ballpark, we are in charted territory, so to speak,

 

 

Chinese Herbs

 

 

" Great spirits have always been violently opposed by mediocre minds " --

Albert Einstein

[Guest guest]

As an aside, I wonder whether anyone can confirm whether the clinical audits that are reported in many chinese journals typically would be comprised of such a self selected group. It is my understanding that patients make their own choice in China to seek out western or TCM care. When these audits are from self selected patients, that would partially explain the extremely high success rates often reported. If we can't rely on our isolated subjective experiences and perhaps not even much of the modern chinese research, where do we put our "faith". I think the only choice we have is to follow the actual tradition as it is recorded in the premodern literature. With regard to form and dosage, there is a wide range in the premodern formularies, but we can identify a low end and high end. the low end is about equivalent to what are used in modern taiwan and japan and the high end is closer to modern PRC style. As long as we stay in this ballpark, we are in charted territory, so to speak

>>>>Agreed, on both points. We need to keep understand this kind of information carefully.

Alon

[Guest guest]

Thank you for saying this. I agree wholeheartedly. . .

especially with your conclusion in that we need to follow the tradition

in the premodern literature.

 

However, and I am sure you agree, that we also need to adapt and forge

new territory in such areas as prescribing herbs to patients who use

pharmaceutical drugs and vitamin-mineral supplements.

 

I have always been a little skeptical of the outcome-based studies done

in China, although I think they are essential for our exposure to

Chinese doctors' methods, prescriptions, and treatments of large

population groups. I am most skeptical of texts such as " Acupuncture

Case Histories " , which make it appear as if one can cure asthma or

diabetes in ten treatments with a simple point selection.

 

 

On Sunday, September 22, 2002, at 10:03 AM, wrote:

 

> As an aside, I wonder whether anyone can confirm whether the clinical

> audits that are reported in many chinese journals typically would be

> comprised of such a self selected group. It is my understanding that

> patients make their own choice in China to seek out western or TCM

> care. When these audits are from self selected patients, that would

> partially explain the extremely high success rates often reported. If

> we can't rely on our isolated subjective experiences and perhaps not

> even much of the modern chinese research, where do we put our " faith " .

> I think the only choice we have is to follow the actual tradition as

> it is recorded in the premodern literature. With regard to form and

> dosage, there is a wide range in the premodern formularies, but we

> can identify a low end and high end. the low end is about equivalent

> to what are used in modern taiwan and japan and the high end is closer

> to modern PRC style. As long as we stay in this ballpark, we are in

> charted territory, so to speak,

[Guest guest]

I have always been a little skeptical of the outcome-based studies done in China, although I think they are essential for our exposure to Chinese doctors' methods, prescriptions, and treatments of large population groups. I am most skeptical of texts such as "Acupuncture Case Histories", which make it appear as if one can cure asthma or diabetes in ten treatments with a simple point selection

>>>>Zev thank you for finally sharing this. To me this is a critical issue that needs to be put upfront, discussed openly and addressed as practitioners in the west

Alon

[Guest guest]

Todd:

 

While you bring up an essential point about self-selection, I think

following the " actual tradition " is difficult since premodern CM is

so diverse and disorganized, and modern CM is too limited and

politicized to reflect the clinical history. And, we have the added

problem of adapting CM to Western concepts.

 

I agree with Z'ev about the spin on the results of many Chinese

studies. We may have to research and verify everything anew for

ourselves since we cannot trust studies that say, for example, that

54% of schizophrenic patients were " cured " by the usual herbal

formulas. Simply on the face of it, studies like these are, at best,

highly suspect.

 

Perhaps if there was some sort of coordinated research effort or

audit of school clinic cases.

 

 

Jim Ramholz

 

 

 

 

>>: When these audits are from self selected patients, that

would partially explain the extremely high success rates often

reported. If we can't rely on our isolated subjective experiences

and perhaps not even much of the modern chinese research, where do

we put our " faith " .

>> I think the only choice we have is to follow the actual

tradition as it is recorded in the premodern literature.

[Guest guest]

, " James Ramholz " <

jramholz> wrote:

:

>

> While you bring up an essential point about self-selection, I

think

> following the " actual tradition " is difficult since premodern CM

is

> so diverse and disorganized,

 

You can never be too precise in email, I guess. I should have

written " actual traditions " (denoting the plurality of methods and

approaches of which we are all aware). While the tradition is not

monolithic and does not give us fixed standards, an examination

of the classical literature certainly informs us as to the range of

norms in certain areas, such as dosage of herbs. Perhaps an

analogy would be helpful. By examining the skeletons of ancient

chinese people, we can determine a range of heights in the

population at any given time. We can speculate that perhaps

there was a large population of extremely small people who

disappeared without a trace, but there is no evidence of this.

Likewise, we cannot say that one should always dispense ren

shen in 6 gram doses, when the literature suggests a much

wider range. But that range does not include the infinitesimal

doses of homeopathy, for example. there is a limit to what we

can say is chinese medicine. the boundaries are wide, but they

exist.

 

Now, if modern practitioners are having the experience that

products prepared and dispensed in a completely different

fashion than ever before in history are nevertheless effective, so

be it. But everyone needs to be honest about this. The use of

low dose patents and liquid extracts is unprecedented in TCM. It

is equally an example of " making stuff up " as all the other MSU

we've argued about. If you are OK with the MSU approach to

TCM (and some of you have overtly stated this), than such a use

of herbs is nperfectly reasonable. But if you oppose MSU as a

guide to practice, I think this position should be extended to your

selection of herb products, as well.

 

Everyone is free to practice as they please and the use of herbs

favored by many americans (cheap, low dose, prepared

medicines and simple tinctures) may indeed be effective. But

this is a development that been more influenced by american

and european herbalism than any recorded chinese tradition.

Since this list has many students with us, I feel compelled to not

let this point ever slip from my radar. It comes up several times

per day in the PCOM clinic. Students need to know that some of

the positions being espoused on this list do not reflect any

chinese traditon I am aware of.

 

While there is plenty that I am not aware of, I have yet to see the

" other side " present citations from the chinese medical literature

to support the use of low dose prepared medicines in serious

illness with severe symptoms (chronic or acute). I know my

opinion is largely shared by those who abhor MSU and have

researched the classical literature extensively on this issue. I

would not stubbornly hold to my postion if I had evidence or

experience to the contrary. It would be sadistic to impose high

does decoctions (or granules) on my patients if there was an

alternative that was anywhere near as effective. but from my

ethical position, it would be more sadistic to explore uncharted

territory with my patients with the tried and true just works so

damn well.

 

The PCOM clinic is very eclectic, so I get to see the results of

many different styles of practice every day. And I am pleasantly

surprised to see that the basic TCM approach to care is at least

as effective as any other style, when it is practiced as intended.

so you can't use tinctures on every patient and then moan that

herbs don't work. for example, treating pain with acupuncture is

not something I typically do when I have a private practice. But in

the PCOM clinic, I treat such patients personally and supervise

their treatment, as well. and basic local distal needling seems

to work just dandily 80% of the time. no fancy imaging, motor

points, deep needling, etc. I try and present what I consider to

be a general consensus of a large number of TCM practitioners

worldwide. It is not elitist, but really quite proletarian.