modeling

[Guest guest]

Dear Colleagues

 

I wanted to say something about modeling in the educational setting and

what I believe constitutes the best education for students. Let me know

what you think. This refers to what PCOM calls Practitioner shifts.

These shifts are done by assistants, which are the level below Interns at

PCOM. Assistant participation is a major objective for the Practitioner

shift, and the performing of clinical procedures, including acupuncture,

should occupy a significant percentage of instructional time. The

Practitioner shift will provide a practice model for students in their

future internship and private practice upon graduation and subsequent

licensure. Patients are told that they will be treated by a team

including one licensed acupuncturist who will have up to 5 students

observing and assisting. Compared to Intern courses, the supervisor will

be responsible for 70-80% fewer patients in these courses. While patients

will still be treated by students, the supervisor devotes far more time to

each case determining diagnosis and treatment plan. This is the key

distinction between intern and practitioner courses.

 

First, lets talk about TCM, the predominant style of chinese medicine

taught at most schools. In my estimate, the primary emphasis of the TCM

style is on diagnosis through questioning and tongue examination. Now

keep in mind I am not suggesting that this style is more " right " or more

" effective " than styles that put predominance on the pulse or abdomen

palpation or other diagnostic measures. I am merely stating what I

observe from Chinese practitioners, translations of chinese internal

medicine texts and numerous modern chinese case studies as the fundamental

pillars of TCM. The information gleaned from these two examinations

(questioning and tongue) is deemed the most reliable. Pulse is used as a

confirmatory sign to rule in or rule out pathology, but the volatility of

the pulse is considered more reliable for making moment to moment

judgments about the patients immediate state than a long term indicator.

Thus a pulse could become fast or wiry or slippery on any given day for

many reasons unrelated to the patients long term health. Plus no two

doctors ever agree on the pulse due to differences in training. The

tongue on the other hand is more stable and it is easy to get consensus

amongst many doctors.

 

This happens to be the style I practice, so my emphasis is similar. I

never dispute what others are doing in their styles, I just point out that

this is TCM and some things are given more weight in different styles than

others. For example, pulse analysis in TCM style emphasizes the quality

of the entire pulse rather than quantifying the force of the pulse in all

12 positions as in some five phase or nan jing. This is abundantly

evident in numerous books on TCM internal medicine in the english language,

including translations of texts going back hundreds of years. It is

decidely NOT a modern communist bastardization. Students are often not

aware that 12 position pulse quantification is not typical in the TCM

style and has essentially no history of use at all in mainstream herbology

as far I can ascertain. Thus when a student uses 12 position

quantification as their primary pulsetaking method, they have devoted

considerable time and effort to gathering data not germane to their TCM

diagnosis and treatment planning and have invariably given short shrift to

other key factors in diagnosis, such as careful questioning. While it is

true that every student needs to get better at the pulse, I feel very

strongly that what they need to get most better at is careful questioning

and analysis of the data. If they plan to practice TCM style or if they

are on my shift, I think they are served much better by devoting their

attention to these details than to non TCM styles of pulsetaking, for

example.

 

The other aspect that I consider essential for modeling is the careful

interpretation of data gathered. I consider this a difficult painstaking

process for beginners that cannot be taken lightly. There are two styles

of doing diagnosis in modern TCM, according to anthropologist Volker

Scheid. Differentiations of types (bian xing) and patterns (bian zheng).

Typing is fairly straightforward. One identifies a disease and the single

type that it matches most closely at that moment in time. Treatment is

then basically textbook with some room for modification. Patterning is

more like examining the entire natural history of the complaint and

considering all the mutually engendering pathomechanisms at play. It is a

decidedly intellectual, analytical, literary and historical process.

Other practitioners practicing other styles necessarily put emphasis

elsewhere. This is especially true if the practitioner thinks of

themselves as primarily or even wholly an acupuncturist.

 

Which finally brings me to acupuncture. If you consider yourself

primarily an acupuncturist and use pulse as your predominant form of

examination, your shifts will devote large amounts of time to these

activities. And less time will be spent in detailed discussion and

analysis, herbal prescribing, etc. This is not a criticism; it is merely

an observation of the requirements of different styles of practice. Many

TCM practitioners, such as almost all of our Chinese staff were originally

trained as either medical doctors or in the internal medicine department

of their respective universities. Their practice largely consisted of

writing prescriptions. Like most TCM style practitioners, they typically

use big points when they do acupuncture. Which is to say, this style

repeatedly calls for the use of the same 50 or so points in various

combinations plus a shi over and over again. While it is certainly

anathema to some to say this, all of us who practice this way have

discovered TCM style acupuncture is as effective as any other style we

have observed over time, especially when practiced in conjunction with

individualized formulas in raw herb form. This is abundantly evident at a

school clinic like PCOM where many styles are practiced.

 

The nice thing about TCM style big point acupuncture, besides the fact

that it works just great in practice despite what detractors might say, is

that it is meshes perfectly with the traditions of internal herbal

medicine throughout chinese history. Points can be easily chosen using

the same diagnosis used to write one's herbal prescription. This is not

only clinically effective, but also models a style of cost effective

practice for those who plan to be serious herbalists. You just can't do

extremely labor intensive bodywork and research and write and fill a

complex formula in the same office visit. At least I can't. Now please

don't mistake my intent here. I consider acupuncture only one of many

important things I am teaching on my shift and its gets what I consider

appropriate coverage for those planning to practice according to the TCM

style.

 

It breaks down about like this:

 

15 minutes - examination of the patient

15 minutes - assessment of information - this involves the discussion part

15 minutes - herbal prescribing - includes research and discussion

15 minutes - acupuncture - done with me in visual range

 

I also often delegate bodywork to massage techs on the shift.

 

I start patients every 45 minutes so we can see more, but I would need at

least an hour per patient if I did everything myself. If I had more rooms

and all upper level assistants, I could see patients every half hour.

 

As stated above, I believe the serious herbalist devote lots of

intellectual time ot their patients cases outside the treatment room. It

is not possible to devote the time necessary to carefully assess and

prescribe in this fashion if one is practicing a style such as Worsley or

bodywork, where the px essentially sits with the patient for the entire 1

hour treatment. Thus, unlike other styles of practice, TCM is really

designed to arrive at the acupuncture plan as a logical derivation of an

intellectual assessment process that was primarily focused on internal

medicine and herbology, rather than being based upon pulse or palpation or

intuition or psychotherapy (all valid in their own right). While I

personally consider myself to have good palpatory skills, I am inclined

towards more intellectual styles myself. On my shifts, I always make the

diagnosis and create the plan. It is my feeling that this is what the

patient is paying extra for. Others, who are wholly hands-on

acupuncturists, believe the patients are paying for their personal hands

to be on them. I would submit that we both are right. If the bodyworker/

pyschotherapist didn't do the treatment, what else would she do that

warranted the higher fee? I spend my time doing detailed questioning and

discussion, ploughing through books, writing prescriptions, overseeing the

filling of herbs AND supervising the students needling my patients.

 

In addition, if a student has already needled the points in my prescribed

plan in class, do they really learn more by seeing me do it or do they

learn more by doing it themselves under my supervision. If they have not

needled in class, they do not needle in clinic under me. period. If I

use a more obscure point or technique, I demonstrate it. But otherwise, I

have to strongly disagree that students benefit most from seeing me needle

ST36 more than seeing me use the time to plan an herbal prescription. I

would also have to reduce my patient load by 25% in order to do most of

the needling myself. Again, I really think this is a style issue and

hinges very much on whether someone is exclusively an acupuncturist or not.

If one's practice is all about unfamiliar techniques like taping the

needle to the skin or exclusively bodywork oriented with lots of tui na,

cupping, etc., of course you will think that is what is most essential to

model.

 

 

 

Chinese Herbs

 

 

" Great spirits have always found violent opposition from mediocre

minds " -- Albert Einstein

[Guest guest]

 

-

 

lynda harvey

Cc: Stacy Gomes ; Jack Miller ; Bob Damone

Thursday, August 21, 2003 9:48 AM

modeling

Dear ColleaguesI wanted to say something about modeling in the educational setting and what I believe constitutes the best education for students. Let me know what you think. This refers to what PCOM calls Practitioner shifts. These shifts are done by assistants, which are the level below Interns at PCOM. Assistant participation is a major objective for the Practitioner shift, and the performing of clinical procedures, including acupuncture, should occupy a significant percentage of instructional time. The Practitioner shift will provide a practice model for students in their future internship and private practice upon graduation and subsequent licensure. Patients are told that they will be treated by a team including one licensed acupuncturist who will have up to 5 students observing and assisting. Compared to Intern courses, the supervisor will be responsible for 70-80% fewer patients in these courses. While patients will still be treated by students, the supervisor devotes far more time to each case determining diagnosis and treatment plan. This is the key distinction between intern and practitioner courses. First, lets talk about TCM, the predominant style of chinese medicine taught at most schools. In my estimate, the primary emphasis of the TCM style is on diagnosis through questioning and tongue examination. Now keep in mind I am not suggesting that this style is more "right" or more "effective" than styles that put predominance on the pulse or abdomen palpation or other diagnostic measures. I am merely stating what I observe from Chinese practitioners, translations of chinese internal medicine texts and numerous modern chinese case studies as the fundamental pillars of TCM. The information gleaned from these two examinations (questioning and tongue) is deemed the most reliable. Pulse is used as a confirmatory sign to rule in or rule out pathology, but the volatility of the pulse is considered more reliable for making moment to moment judgments about the patients immediate state than a long term indicator. Thus a pulse could become fast or wiry or slippery on any given day for many reasons unrelated to the patients long term health. Plus no two doctors ever agree on the pulse due to differences in training. The tongue on the other hand is more stable and it is easy to get consensus amongst many doctors. This happens to be the style I practice, so my emphasis is similar. I never dispute what others are doing in their styles, I just point out that this is TCM and some things are given more weight in different styles than others. For example, pulse analysis in TCM style emphasizes the quality of the entire pulse rather than quantifying the force of the pulse in all 12 positions as in some five phase or nan jing. This is abundantly evident in numerous books on TCM internal medicine in the english language, including translations of texts going back hundreds of years. It is decidely NOT a modern communist bastardization. Students are often not aware that 12 position pulse quantification is not typical in the TCM style and has essentially no history of use at all in mainstream herbology as far I can ascertain. Thus when a student uses 12 position quantification as their primary pulsetaking method, they have devoted considerable time and effort to gathering data not germane to their TCM diagnosis and treatment planning and have invariably given short shrift to other key factors in diagnosis, such as careful questioning. While it is true that every student needs to get better at the pulse, I feel very strongly that what they need to get most better at is careful questioning and analysis of the data. If they plan to practice TCM style or if they are on my shift, I think they are served much better by devoting their attention to these details than to non TCM styles of pulsetaking, for example.The other aspect that I consider essential for modeling is the careful interpretation of data gathered. I consider this a difficult painstaking process for beginners that cannot be taken lightly. There are two styles of doing diagnosis in modern TCM, according to anthropologist Volker Scheid. Differentiations of types (bian xing) and patterns (bian zheng). Typing is fairly straightforward. One identifies a disease and the single type that it matches most closely at that moment in time. Treatment is then basically textbook with some room for modification. Patterning is more like examining the entire natural history of the complaint and considering all the mutually engendering pathomechanisms at play. It is a decidedly intellectual, analytical, literary and historical process. Other practitioners practicing other styles necessarily put emphasis elsewhere. This is especially true if the practitioner thinks of themselves as primarily or even wholly an acupuncturist.Which finally brings me to acupuncture. If you consider yourself primarily an acupuncturist and use pulse as your predominant form of examination, your shifts will devote large amounts of time to these activities. And less time will be spent in detailed discussion and analysis, herbal prescribing, etc. This is not a criticism; it is merely an observation of the requirements of different styles of practice. Many TCM practitioners, such as almost all of our Chinese staff were originally trained as either medical doctors or in the internal medicine department of their respective universities. Their practice largely consisted of writing prescriptions. Like most TCM style practitioners, they typically use big points when they do acupuncture. Which is to say, this style repeatedly calls for the use of the same 50 or so points in various combinations plus a shi over and over again. While it is certainly anathema to some to say this, all of us who practice this way have discovered TCM style acupuncture is as effective as any other style we have observed over time, especially when practiced in conjunction with individualized formulas in raw herb form. This is abundantly evident at a school clinic like PCOM where many styles are practiced. The nice thing about TCM style big point acupuncture, besides the fact that it works just great in practice despite what detractors might say, is that it is meshes perfectly with the traditions of internal herbal medicine throughout chinese history. Points can be easily chosen using the same diagnosis used to write one's herbal prescription. This is not only clinically effective, but also models a style of cost effective practice for those who plan to be serious herbalists. You just can't do extremely labor intensive bodywork and research and write and fill a complex formula in the same office visit. At least I can't. Now please don't mistake my intent here. I consider acupuncture only one of many important things I am teaching on my shift and its gets what I consider appropriate coverage for those planning to practice according to the TCM style.It breaks down about like this:15 minutes - examination of the patient15 minutes - assessment of information - this involves the discussion part15 minutes - herbal prescribing - includes research and discussion15 minutes - acupuncture - done with me in visual rangeI also often delegate bodywork to massage techs on the shift.I start patients every 45 minutes so we can see more, but I would need at least an hour per patient if I did everything myself. If I had more rooms and all upper level assistants, I could see patients every half hour.As stated above, I believe the serious herbalist devote lots of intellectual time ot their patients cases outside the treatment room. It is not possible to devote the time necessary to carefully assess and prescribe in this fashion if one is practicing a style such as Worsley or bodywork, where the px essentially sits with the patient for the entire 1 hour treatment. Thus, unlike other styles of practice, TCM is really designed to arrive at the acupuncture plan as a logical derivation of an intellectual assessment process that was primarily focused on internal medicine and herbology, rather than being based upon pulse or palpation or intuition or psychotherapy (all valid in their own right). While I personally consider myself to have good palpatory skills, I am inclined towards more intellectual styles myself. On my shifts, I always make the diagnosis and create the plan. It is my feeling that this is what the patient is paying extra for. Others, who are wholly hands-on acupuncturists, believe the patients are paying for their personal hands to be on them. I would submit that we both are right. If the bodyworker/pyschotherapist didn't do the treatment, what else would she do that warranted the higher fee? I spend my time doing detailed questioning and discussion, ploughing through books, writing prescriptions, overseeing the filling of herbs AND supervising the students needling my patients. In addition, if a student has already needled the points in my prescribed plan in class, do they really learn more by seeing me do it or do they learn more by doing it themselves under my supervision. If they have not needled in class, they do not needle in clinic under me. period. If I use a more obscure point or technique, I demonstrate it. But otherwise, I have to strongly disagree that students benefit most from seeing me needle ST36 more than seeing me use the time to plan an herbal prescription. I would also have to reduce my patient load by 25% in order to do most of the needling myself. Again, I really think this is a style issue and hinges very much on whether someone is exclusively an acupuncturist or not. If one's practice is all about unfamiliar techniques like taping the needle to the skin or exclusively bodywork oriented with lots of tui na, cupping, etc., of course you will think that is what is most essential to model. Chinese Herbshttp://www..orgvoice: fax: "Great spirits have always found violent opposition from mediocre minds" -- Albert Einstein

[Guest guest]

, wrote:

Thus when a student uses 12 position quantification as their primary

pulse taking method, they have devoted considerable time and effort

to gathering data not germane to their TCM diagnosis and treatment

planning and have invariably given short shrift to other key factors

in diagnosis, such as careful questioning. While it is true that

every student needs to get better at the pulse, I feel very strongly

that what they need to get most better at is careful questioning and

analysis of the data. >>>

 

:

 

Your general impression of the role of pulse diagnosis and how it

practiced in most TCM schools is not inaccurate. But for a few

exceptions, pulse diagnosis is largely glossed over in class---it is

a lost art in the process of revival.

 

Coming out of school, I doubt all but a few can recognize the 27 Li

Shizhen pulse catagories---which is the most basic system.

Consequently, the role of pulse diagnosis in a school clinic is very

limited. Although the Nan Jing and Mai Jing have the foundations for

some very sophisticated pulse models, by Li Shizhen's time it is my

impression that interest in the art of pulses seemed to be waining.

 

The problem actually stems from there being too few interested and

qualified teachers. Besides, hardly anyone has the time or stamina

of attention to examine the patient's pulses for an hour---let alone

do it in a school clinic setting. In a school clinic, there is not

enough time for it to be more than a confirmatory sign. But it is

inaccurate to say the data is " not germaine " to the patient or the

TCM diagnostic process.

 

Unless pulse diagnosis is taught well and practiced from the

beginning, it should probably be reserved as a specialty for the

doctoral or postgraduate level.

 

Other than these minor criticisms, your proposal seems sound and

worth trying.

 

 

Jim Ramholz

[Guest guest]

Todd: <<<Thus when a student uses 12 position quantification as their primary

pulse taking method, they have devoted considerable time and effort

to gathering data not germane to their TCM diagnosis and treatment

planning and have invariably given short shrift to other key factors

in diagnosis, such as careful questioning. While it is true that

every student needs to get better at the pulse, I feel very strongly

that what they need to get most better at is careful questioning and

analysis of the data. >>>

 

and Jim -

 

I agree with you on this, the twelve position method of Nan Jing is primarily

for channel diagnosis. I take it some of your students are learning this

method?

 

It is common for students to overemphasize new concepts in an attempt to

achieve competence; this is often at the expense of other essential procedures.

In

addition, students are inquisitive and will often entertain theories outside

the interest and focus of the preceptor. However, it is the job of clinical

faculty members to set the boundaries when precepting.

 

One area that is missing in most internships is a complete western physical

exam. This is a med-legal necessity in California and any other state where

practitioners are functioning independent of physician oversite. It boils down

to

what is most essential given the available time. And...this conversation

suggests there is insufficient time in the current curricular model to achieve

these competencies regarding diagnosis let alone business practices,

professionalism, and systems based medicine.....

 

Li Zhishen is characterised as simple by Jim, yet the Bin Hu Mai Xue

discusses the method of rolling in four directions and eight extra vessel pulse

system; Li does not discuss interpretation of these findings. Dr Shen also spoke

of

rolling in the four directions - a read of Hammer's book shows an anatomical

interpretation. Chapter Four of the Ling Shu discusses the elements and the

four directions and the last paragraph suggests an implicit use for pulse

diagnosis. I discussed this in my article called 'The Compass Method' in

Acupuncture

Today.

 

Students have variable capacity for knowledge. It would be a shame to see a

practitioner go into practice and have a limited pulse vocabulary of fast-slow,

superficial-deep, wiry-slippery because of a lowest common denominator. Yet,

this is what happens. Anyway - I will be teaching in Santa Cruz in early

October, Los Angeles early December, and Sarasota FL in November if anyone is

interested please contact me off list..

 

William R. Morris, OMD

Secretary, AAOM

Academic Dean

Emperor's College of TOM

310-453-8383

 

 

 

 

[Guest guest]

Will Morris wrote:

>>>Students have variable capacity for knowledge. It would be a shame to see

a

practitioner go into practice and have a limited pulse vocabulary of

fast-slow,

superficial-deep, wiry-slippery because of a lowest common denominator. Yet,

this is what happens.<<<

 

Will,

In my experience, what happens is that students tend to focus on the

individual positions like spleen, liver, kidneys, etc., and find " wiriness " and

" slipperiness " everywhere, and basically ignore the overall pulse parameters of

fast-slow, superficial-deep, wide-narrow, etc. I am continually harping at my

interns to tell me what the overall pulse picture is. You cannot make sense of

the

trees until you understand the forest. To me, it is much more important to

know that a patient's pulse is, for example, getting stronger and more full as

it goes distal on both sides than that the kidney is weak and the heart feels

full. The overall reading tells me that the person has energy, probably heat

energy, rising up in their body. They may have HBP or tinnitus or

neck/shoulder/upper back pain or whatnot. They obviously have qi riding up. You

can't tell

that very well from a bunch of isolated position readings. Very often, all I

really need to know is the information I find in the overall reading, which I

keep not getting from my individual-position trained students.

Joseph Garner

 

 

 

[Guest guest]

, acugrpaz@a... wrote:

Very often, all I really need to know is the information I find in

the overall reading, which I keep not getting from my individual-

position trained students.

 

 

 

Joseph:

 

This is really a personal choice and not a reliable criteria for

training students in pulse diagnosis. Some patients may come in with

simple patterns and that's all you may need. But some patients come

in with much more complex patterns; that's why all the different

pulse methods developed and continue to change over the years.

 

For example, it's not a matter of choice for the practitioner if the

right proximal shows kidney yang, TW/Pc, Bladder/front lower

abdomen, SI, or the brain---you don't get to choose. The patient has

already " decided " in the way their problem manifests; so it is

really a matter of *when* does the right proximal show any one of

these in a particular patient or condition.

 

If you've only studied one or two and not the others, then those

other patients can easily be misdiagnosed or essential features of

their condition can be overlooked.

 

To reframe the question Todd focuses on---if I'm reading his post

correctly---is how much do we train students in a particular area,

with the limited time that they have available. Todd sets a priority

which makes sense. Unavoidably, there are going to be areas of study

thought to be essential that are going to be left undeveloped. I

would say pulses, some might say translation skills, others might

say biomedical skills.

 

Both pulses and translation skills are fairly labor intensive, and

require a number of years to mature. If they are going to be taught

well at all, they should be started immediately. If they can't be

begun immediately, then time in a postgraduate or specialty courses

should be set aside to do them justice. In any case, it's clear that

we need to rethink what the students need and how to deliver it.

 

 

Jim Ramholz

[Guest guest]

, WMorris116@A... wrote:

Chapter Four of the Ling Shu discusses the elements and the four

directions and the last paragraph suggests an implicit use for pulse

diagnosis. >>>

 

 

Will:

 

We interpret the Ling Shu passage as being a metaphor for the 5-

Element deconstruction of the pulse. If you see the pulse as a sine

wave, the ascending portion is wood, the cresting portion is fire,

the descending motion is metal, and the trough or returning is

water; earth is 18 degrees out of each or associated by the overall

balance. If we think of the face of a clock, each movement centers

around 9, 12, 3, and 6 o'clock respectively. So the pulse actually

reflects both the daily and seasonal movement of time on a smaller

scale. The spatial directions are derived simply by association.

 

 

Jim Ramholz

[Guest guest]

Will,

And I agree with you. I just want to say that it is definitely the

preceptor's responsibility to lay out the desired diagnostic parameters for

students to

focus on prior to engagement. However, in the past our students have been

trained (by others) to focus pretty much only on individual positions in the

pulse, and it is a very hard habit to break. For the last two years we have

altered

the curriculum to bring students along slowly with pulse reading, beginning

in the first year with only overall impressions: rate, rhythm, variabilities,

overall pulse pattern, depth, burners, etc., and then slowly taking that into

individual position reading. And only now are some of those students beginning

to be in clinic. I look forward to supervising them: I should not have as much

trouble interacting with them vis-a-vis pulse taking.

 

I am proud of our present pulse training. It is so much more and so much

better than what I and most people I know got in school. Pulse taking is like

face/body reading. It's really not that difficult if you approach it properly.

We

all think we have to wait 20 or 30 years to master pulse reading, and while

mastery remains an elusive idea to quantify, I believe we can all be extremely

proficient in a relatively short time if we are systematic, thorough and allow

ourselves to go slow with the process. Slow-fast, I call it. The more slowly

we learn it, the more quickly we get good at it. Naturally. As far as the pulse

terminology problem goes, I believe we should end the classroom pulse

training time prior to interning time with the 27 or so terms and make students

memorize them, but then allow them in student clinic to describe the pulses any

way

that communicates what they felt, then ultimately, later, go back and reteach

the pulse terminology now that they've been naming pulses for awhile, and it

will all make a lot more sense, and they will understand much better what the

terminology is all about, and what consensus terms to apply to what they've

been feeling, and, toward the end of their time in student clinic, then we can

require precise terminology of them. Each term, after all, does not refer to

one particular pulse sensation, but to a category of sensations, n'est ce-pas?

Even Hammer's voluminous terminologies only describe ranges of sensation, not

perfectly particular ones.

Joseph

 

>>>Hi Joseph -

 

I agree with you. First impressions and big picture are most important, then

large sections, individual positions, and complementary positions in order of

importance. Although, a localized disease process warrants focus on a

particular region. And - rhythm and rate are imperial. Available time and the

interest/skills of the intern and preceptor will define the depth of information

gathering and analysis.

 

It does remain the preceptors responsability to identify the intern's skill

level and define the expectations for the intern prior to engagement in the

clinical process. This will nip many problems in the bud.

 

 

Best regards,

 

Will

 

Will,

In my experience, what happens is that students tend to focus on the

individual positions like spleen, liver, kidneys, etc., and find " wiriness "

and

" slipperiness " everywhere, and basically ignore the overall pulse parameters

of

fast-slow, superficial-deep, wide-narrow, etc. I am continually harping at my

 

interns to tell me what the overall pulse picture is. You cannot make sense

of the

trees until you understand the forest. To me, it is much more important to

know that a patient's pulse is, for example, getting stronger and more full

as

it goes distal on both sides than that the kidney is weak and the heart feels

 

full. The overall reading tells me that the person has energy, probably heat

energy, rising up in their body. They may have HBP or tinnitus or

neck/shoulder/upper back pain or whatnot. They obviously have qi riding up.

You can't tell that very well from a bunch of isolated position readings. Very

often, all I

really need to know is the information I find in the overall reading, which I

 

keep not getting from my individual-position trained students.

Joseph Garner<<<

 

 

 

[Guest guest]

>>>Joseph:

Can you lay out a syllabus and what you expect students to know by

the time clinic comes up. It might fit well in Todd's situation.

Jim Ramholz<<<

 

Jim,

As Curly would say, soytunly. I shall describe our scenario without full

syllabus detail. We have two simultaneous course tracks in which students

receive

pulse training, OM theory and OM/AP practicum. In the first semester theory

class students receive a few hours of pulse reading training a la Hammer's

overall pulse parameters: rate, rhythm, variability, burners, depths, overall

pulse

pattern, width, basic strength and so on, as I referred to in a previous

post. Students are strongly encouraged (vehemently encouraged) not to try to go

any further with their pulse reading than these parameters until we say so. In

this class they are not required to regurgitate any pulse information or

demonstrate any skill.

 

During second semester practicum class, students are taught at length and

required to demonstrate skill at basic eight-principle type information from a

pulse: speed, depth, width, strength, etc.-- all the previously mentioned (and

taught) parameters. During third semester practicum class, students are trained

in and required to demonstrate reading individual positions. We give them a

taste of Shudo Denmei's style, without any dogma attached, to let them know

there are different ways people accurately read pulses, oddly enough. On the

other hand (no pun intended), we do our best not to confuse students, so we

emphasize the similarities in styles, not the differences. In third semester

theory

class they also get some similar pulse theory training and are required to

demonstrate understanding of pulses at a similar level. During fourth semester

practicum class students are taught the pulse terminology from The Web that Has

No Weaver and are required to memorize the terms and demonstrate the ability

to find them on people as much as possible.

 

After fourth semester, students are allowed to intern. They have been

observing much of that time already. As a supervisor, I allow my students to

name the

pulses any way they choose that conveys clarity of meaning to me and then,

later, in clinic, I reteach the terminology when it seems appropriate to me to

do so, but this is not presently school policy. Other people are not quite as

flexible with words as I, more's the pity. Hope this helps.

Joseph Garner

 

 

 

[Guest guest]

All,

Regarding the latest thread about pulse diagnosis, I would like to share my

take on pulses. I believe that Nan Jing style pulse reading, Shen/Hammer style,

Li Shi Zhen style, and Korean Dong Han style can all deliver clinically

accurate and useful information. The reason I think this is as follows.

 

I believe that the organ readings are found at the locations Shen/Hammer

describe, laid out like a mini-map of the body and its burners, just like ears,

soles of the feet, hands, and on and on. I also think the channel readings are

found at the locations the Nan Jing describes. For example, at the right distal

position, I believe the lung organ is read at the lower half or third, with

the lung channel reading at the upper depth of the organ depth, and the upper

depth of the position as a whole reflects both the qi of the lung and the large

intestine channel. The large intestine organ reading, however, is elsewhere,

in the distal part of the lower burner area on the left hand. And, for another

example, the small intestine channel can be read at the upper level of the

left distal position, but the small intestine organ is read between the middle

and lower burners on the right hand. To me this tidies up most, if not all,

discrepancies.

 

As for the right proximal position, I think it does definitely reflect kidney

yang AND mingmen AND san jiao and pericardium channels. These are all

different aspects and elements of the same ballpark. The mingmen is a yang

manifestation of the combination of kidney yin, yang and essence. To me, it's

sort of

the eldest son of mom and pop kidney. The san jiao and pericardium channels

essentially circulate this energy throughout the burners and connect the

mingmen/kidney complex to the heart. I believe the bladder organ is read in this

same

area, just proximal to the right third position, and the prostate in men is

read slightly more proximal still, just like in the body. In women, their

ovaries/uterus energies are split between the left and right hands, and fibroids

and

such can definitely be detected and read easily there when there is any kind

of a lumpy feeling in the pulse. You can easily tell how big the lump(s)

is(are) and, over time, whether they are enlarging or going away. Do not,

however,

think you have fibroids just because you can feel a pulse there. You will know

when you feel lumpiness.

 

At the same time, I think the triad of heaven-man-earth plays out not only in

the burners but in the depths. In the pulses Shen/Hammer accurately describe

this as qi-blood-yin or organ depths. Within each of these three depths, there

are three subdivisions--heaven-man-earth or qi-blood-yin. Within each of

these subdivisions there are three subdivisions and on into infinity. It goes

all

the way in and all the way out into the universe, and it applies to depths as

well as widths. It plays out everywhere on the body and everywhere in the

universe. First there was the one--the tai ji--then the two--yin and yang--then

the three--heaven-man-earth--and THEN the ten thousand things. Anyway, this is

what I think. What do you think about what I think?

Joseph Garner

 

 

 

[Guest guest]

Hi Joseph -

 

I agree with you. First impressions and big picture are most important, then

large sections, individual positions, and complementary positions in order of

importance. Although, a localized disease process warrants focus on a particular

region. And - rhythm and rate are imperial. Available time and the

interest/skills of the intern and preceptor will define the depth of information

gathering and analysis.

 

It does remain the preceptors responsability to identify the intern's skill

level and define the expectations for the intern prior to engagement in the

clinical process. This will nip many problems in the bud.

 

 

Best regards,

 

Will

 

Will,

In my experience, what happens is that students tend to focus on the

individual positions like spleen, liver, kidneys, etc., and find " wiriness " and

" slipperiness " everywhere, and basically ignore the overall pulse parameters of

fast-slow, superficial-deep, wide-narrow, etc. I am continually harping at my

interns to tell me what the overall pulse picture is. You cannot make sense of

the

trees until you understand the forest. To me, it is much more important to

know that a patient's pulse is, for example, getting stronger and more full as

it goes distal on both sides than that the kidney is weak and the heart feels

full. The overall reading tells me that the person has energy, probably heat

energy, rising up in their body. They may have HBP or tinnitus or

neck/shoulder/upper back pain or whatnot. They obviously have qi riding up. You

can't tell

that very well from a bunch of isolated position readings. Very often, all I

really need to know is the information I find in the overall reading, which I

keep not getting from my individual-position trained students.

Joseph Garner

[Guest guest]

JIm: <<We interpret the Ling Shu passage as being a metaphor for the 5-Element

deconstruction of the pulse. If you see the pulse as a sine wave, the ascending

portion is wood, the cresting portion is fire, the descending motion is metal,

and the trough or returning is water; earth is 18 degrees out of each or

associated by the overall balance. If we think of the face of a clock, each

movement centers around 9, 12, 3, and 6 o'clock respectively. So the pulse

actually reflects both the daily and seasonal movement of time on a smaller

scale. The spatial directions are derived simply by association.>>

 

Hi JIm -

 

I also use this method in the Neoclassical system. However, my source is Wang

Shuhe. That passage from Chapter four is robust. We are talking about it's

application in a vertical plane vs a horizontal plane as well as a spatial vs

temporal aspect. They are all valid.

 

Best regards,

 

Will

[Guest guest]

, acugrpaz@a... wrote:

It is so much more and so much better than what I and most people I

know got in school. Pulse taking is like face/body reading. It's

really not that difficult if you approach it properly. We

all think we have to wait 20 or 30 years to master pulse reading,

and while mastery remains an elusive idea to quantify, I believe we

can all be extremely proficient in a relatively short time if we are

systematic, thorough and allow ourselves to go slow with the

process.>>>

 

 

Joseph:

 

Can you lay out a syllabus and what you expect students to know by

the time clinic comes up. It might fit well in Todd's situation.

 

 

Jim Ramholz

[Guest guest]

, acugrpaz@a... wrote:

> As Curly would say, soytunly. I shall describe our scenario

without full syllabus detail. >>>

 

:

 

This seems like a practical arrangement for teaching pulses in

school. Does this match the time and level of detail for what you're

doing at PCOM, and not conflict with the other diagnostic methods

you were speaking about?

 

 

Jim Ramholz

[Guest guest]

<<It's really not that difficult if you approach it properly. We all think we

have to wait 20 or 30 years to master pulse reading, and while mastery remains

an elusive idea to uantify, I believe we can all be extremely proficient in a

relatively short time if we are systematic, thorough and allow ourselves to go

slow with the process.>>

 

Joseph - here here. This is true. I am on limited access heading into the

mountains with Unschuld tommorrow and connot discourse.

 

Best regards,

 

Will

[Guest guest]

This is a very important discussion, one I have all

the time with students and practitioners (especially

new ones) in the clinic. The overall pulse pattern is

most important to develop correct treatment plan that

is not confused by too many parameters. Practitioners

become confused in diagnosis by trying to feel too

many aspects of the pulse rather than the general

patterns and their direction.

Thanks for this good discussion.

Misha---

acugrpaz wrote:

> Will Morris wrote:

> >>>Students have variable capacity for knowledge. It

> would be a shame to see

> a

> practitioner go into practice and have a limited

> pulse vocabulary of

> fast-slow,

> superficial-deep, wiry-slippery because of a lowest

> common denominator. Yet,

> this is what happens.<<<

>

> Will,

> In my experience, what happens is that students tend

> to focus on the

> individual positions like spleen, liver, kidneys,

> etc., and find " wiriness " and

> " slipperiness " everywhere, and basically ignore the

> overall pulse parameters of

> fast-slow, superficial-deep, wide-narrow, etc. I am

> continually harping at my

> interns to tell me what the overall pulse picture

> is. You cannot make sense of the

> trees until you understand the forest. To me, it is

> much more important to

> know that a patient's pulse is, for example, getting

> stronger and more full as

> it goes distal on both sides than that the kidney is

> weak and the heart feels

> full. The overall reading tells me that the person

> has energy, probably heat

> energy, rising up in their body. They may have HBP

> or tinnitus or

> neck/shoulder/upper back pain or whatnot. They

> obviously have qi riding up. You can't tell

> that very well from a bunch of isolated position

> readings. Very often, all I

> really need to know is the information I find in the

> overall reading, which I

> keep not getting from my individual-position trained

> students.

> Joseph Garner

>

>

> [Non-text portions of this message have been

> removed]

>

>

>

[Guest guest]

I don't think that the point is that all types of

pulse diagnosis should not be taught but that how to

develop an understanding in when to use which system

or whether to focus on individual Organs, Xue, Qi and

Fluids, Channels or overall patterns of the pulse.

This is the true teaching as far as I am concerned.

Misha

> Joseph:

>

> This is really a personal choice and not a reliable

> criteria for

> training students in pulse diagnosis. Some patients

> may come in with

> simple patterns and that's all you may need. But

> some patients come

> in with much more complex patterns; that's why all

> the different

> pulse methods developed and continue to change over

> the years.

>

> For example, it's not a matter of choice for the

> practitioner if the

> right proximal shows kidney yang, TW/Pc,

> Bladder/front lower

> abdomen, SI, or the brain---you don't get to choose.

> The patient has

> already " decided " in the way their problem

> manifests; so it is

> really a matter of *when* does the right proximal

> show any one of

> these in a particular patient or condition.

>

> If you've only studied one or two and not the

> others, then those

> other patients can easily be misdiagnosed or

> essential features of

> their condition can be overlooked.

>

> To reframe the question Todd focuses on---if I'm

> reading his post

> correctly---is how much do we train students in a

> particular area,

> with the limited time that they have available. Todd

> sets a priority

> which makes sense. Unavoidably, there are going to

> be areas of study

> thought to be essential that are going to be left

> undeveloped. I

> would say pulses, some might say translation skills,

> others might

> say biomedical skills.

>

> Both pulses and translation skills are fairly labor

> intensive, and

> require a number of years to mature. If they are

> going to be taught

> well at all, they should be started immediately. If

> they can't be

> begun immediately, then time in a postgraduate or

> specialty courses

> should be set aside to do them justice. In any case,

> it's clear that

> we need to rethink what the students need and how to

> deliver it.

>

>

> Jim Ramholz

>

>

>

>

>

>

[Guest guest]

, Misha Cohen wrote:

> I don't think that the point is that all types of

> pulse diagnosis should not be taught but that how to

> develop an understanding in when to use which system

> or whether to focus on individual Organs, Xue, Qi and

> Fluids, Channels or overall patterns of the pulse.

> This is the true teaching as far as I am concerned. >>>

 

 

Misha:

 

This is similar to the points I was trying to make. You can take

pulse diagnosis as far as you are interested and capable. Like

learning a musical instrument, the subject is so deep that it can

take a whole lifetime.

 

But the real question is 'how much can you teach and what is

diagnostically reliable within the time limits set by the school.'

Joseph came up with a reasonable syllabus. Like translation, most

think it is important but argue as to what should be taught and how

much beginning students should be responsible for---and if there are

enough good teachers to accomplish it.

 

There are basic features common to most systems---typically the

material found in the Nan Jing and Li Shizhen. The curriculum

material for pulses should probably be drawn from these, since these

are the basic texts.

 

 

 

Jim Ramholz

[Guest guest]

I just got back from doing a pulse workshop at Bastyr University in

Seattle, based on Nan Jing pulse, but also referencing Li Shih-zhen and

the Mai Jing. I got some sense of what students and practitioners

need, and will be proposing some changes to the PCOM cirriculum in the

next several months based on the information I've presented and gotten

feedback on.

 

 

On Sunday, August 24, 2003, at 09:59 AM, James Ramholz wrote:

 

> Joseph:

>

> Can you lay out a syllabus and what you expect students to know by

> the time clinic comes up. It might fit well in Todd's situation.

>

>

> Jim Ramholz

[Guest guest]

When the air becomes safe (from viruses) again, I'll send an

attachment to the CHA site on an article I wrote on how to rectify

jing-luo and zang-fu pulse maps, and how Difficulty 18 in the Nan Jing

reconciles the channel and zang-fu pulse models. I'll wait for

your cue.

 

 

On Sunday, August 24, 2003, at 11:33 AM, acugrpaz wrote:

 

> All,

> Regarding the latest thread about pulse diagnosis, I would like to

> share my

> take on pulses. I believe that Nan Jing style pulse reading,

> Shen/Hammer style,

> Li Shi Zhen style, and Korean Dong Han style can all deliver clinically

> accurate and useful information. The reason I think this is as follows.

>

> I believe that the organ readings are found at the locations

> Shen/Hammer

> describe, laid out like a mini-map of the body and its burners, just

> like ears,

> soles of the feet, hands, and on and on. I also think the channel

> readings are

> found at the locations the Nan Jing describes. For example, at the

> right distal

> position, I believe the lung organ is read at the lower half or third,

> with

> the lung channel reading at the upper depth of the organ depth, and

> the upper

> depth of the position as a whole reflects both the qi of the lung and

> the large

> intestine channel. The large intestine organ reading, however, is

> elsewhere,

> in the distal part of the lower burner area on the left hand. And, for

> another

> example, the small intestine channel can be read at the upper level of

> the

> left distal position, but the small intestine organ is read between

> the middle

> and lower burners on the right hand. To me this tidies up most, if not

> all,

> discrepancies.

>

> As for the right proximal position, I think it does definitely reflect

> kidney

> yang AND mingmen AND san jiao and pericardium channels. These are all

> different aspects and elements of the same ballpark. The mingmen is a

> yang

> manifestation of the combination of kidney yin, yang and essence. To

> me, it's sort of

> the eldest son of mom and pop kidney. The san jiao and pericardium

> channels

> essentially circulate this energy throughout the burners and connect

> the

> mingmen/kidney complex to the heart. I believe the bladder organ is

> read in this same

> area, just proximal to the right third position, and the prostate in

> men is

> read slightly more proximal still, just like in the body. In women,

> their

> ovaries/uterus energies are split between the left and right hands,

> and fibroids and

> such can definitely be detected and read easily there when there is

> any kind

> of a lumpy feeling in the pulse. You can easily tell how big the

> lump(s)

> is(are) and, over time, whether they are enlarging or going away. Do

> not, however,

> think you have fibroids just because you can feel a pulse there. You

> will know

> when you feel lumpiness.

>

> At the same time, I think the triad of heaven-man-earth plays out not

> only in

> the burners but in the depths. In the pulses Shen/Hammer accurately

> describe

> this as qi-blood-yin or organ depths. Within each of these three

> depths, there

> are three subdivisions--heaven-man-earth or qi-blood-yin. Within each

> of

> these subdivisions there are three subdivisions and on into infinity.

> It goes all

> the way in and all the way out into the universe, and it applies to

> depths as

> well as widths. It plays out everywhere on the body and everywhere in

> the

> universe. First there was the one--the tai ji--then the two--yin and

> yang--then

> the three--heaven-man-earth--and THEN the ten thousand things. Anyway,

> this is

> what I think. What do you think about what I think?

> Joseph Garner

>

>

>