Guest guest Posted April 5, 2004 Report Share Posted April 5, 2004 > It would be impossible to calibrate the > practitioners in a study for pulse dx without at least a full day of > orientation, but this may be worth it. Since herbal texts rarely get into > extremely nuanced pulsetaking, herbal studies should be similarly > structured in this regard. Give researchers a few set variables to define > in the pulse rather making a freeform pulse dx. It is easier to calibrate > for things like superficial vs. deep, forceful vs. forceless, fast vs. > slow, irregular vs, regular than it is for things like wiry, slippery and > choppy. While I agree with your statements, it is also important to note that even an orientation is inadequate. To fully answer objections to TCM Dx as the foundation of a study, there needs to be pilot studies showing that those participating in the study have acceptable degrees of inter-rater agreement. Recording the tongue images, an excellent idea in itself, is appropriate to opening the study to review, however, it too must be supported by evidence that the tongue interpretations are inter-rater reliable. It is also critical that the record keeping system by which the data is gathered and assessed be reliable. There needs to be evidence that every clinical observation that is a study variable but is not supported by exclusionary tests and standard measures can be reported reliably by the assessors. Bob Robert L. Felt bob Paradigm Publications www.paradigm-pubs.com 202 Bendix Drive 505 758 7758 Taos, New Mexico 87571 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 5, 2004 Report Share Posted April 5, 2004 , " Robert L. Felt " <bob@p...> wrote: > > While I agree with your statements, it is also important to note that even an > orientation is inadequate. I only meant adequate to calibrate, not to actually verify inter-rater reliability. To fully answer objections to TCM Dx as the > foundation of a study, there needs to be pilot studies showing that those > participating in the study have acceptable degrees of inter-rater agreement. I used to feel this way and we have discussed it here at length. Yet the NIH keeps approving OM studies, none of which address this issue. And in critiques of studies already done, this concern is also rarely heard. I believe eventually this critique will be raised as the opposition keeps moving the goalposts. But it does not seem an impediment to getting funding or acceptance of study results at the current time. Ironically, this should be a much larger concern than the sham issue. I think part of the reason no one is touching this issue yet is because so little of the subjective aspect of WM is inter-rater reliable. WM sidesteps this issue to some extent by moving more and more away from subjective assessment as a basis of dx. Yet subjective assessment remains vital to WM practice and no one wants to raise theissue of how often doctors are wrong. Unless we also plan to make this move towards diagnostic objectivity, we will have to inevitably address this matter. Personally, I consider tongue dx to be pretty objective as long as paramaters are predefined. It is pretty easy to agree on what you see as long as people aren't colorblind. It is really the pulse alone that presents a challenge in modern TCM dx. But I wonder if we can ever satisfactorily address this matter of subjective dx and thus must necessarily move in the direction of objective confirmations. I believe this is why TCM downplays the pulse. The reason is that even if we can calibrate a group of researchers and prove that this calibrated group can demonstrate inter-rater reliability, this still proves nothing about the safety and efficacy of standard practice in TCM. If TCM is the defacto standard in the US, then everyone is trained to make a TCM diagnosis. That means you should be able to throw ten random px in a room and get them all in the same ballpark. You show ten cardiologists the same EKG and you get some honest differences of opinion, but it is also clear that they are looking at the same thing. Lines of differing length on a graph. On the other hand, it is often just as clear to me that my interns are not sensing what I sense (and not that I am necessarily right, but just that agreement on tactile stimuli has proven very unreliable compared to visual in perception studies). But if one person says choppy and another says slippery, the image in each mind is quite different. It is if they are looking at different EKG's. This is quite different than two people saying slippery and still coming up with a different dx based upon differing experience with pattern differentiation. At least they are " looking " at the same thing. Since this type of inter-rater reliability requires calibration before a study (while tongue and questioning only require defined parameters, IMO), the question would immediately be raised after a study as to why one should trust an uncalibrated practitioner. In other words, if only a calibrated researcher can make a reliable dx, then that discredits most acupuncturists in practice if they cannot make the required dx w/o calibration. could be a windfall for pulse workshops. :-) I would suggest that if no one demands we calibrate and verify inter-rater reliability, that doing so in studies might work against us. If we show that defined standard parameters lead to effective tx even in the absence of verified inter-rater reliability, then we do not limit the application of the results to calibrated px only. I suspect that studies that demonstrate the requirement of standardized calibration for effective tx will meet great resistance in our anything goes field. On the other hand, the demonstrated need for well calibrated diagnostic skills could strengthen the case for extensive training in traditinal oriental medical theory and the superiority of thusly trained px. If we prove calibration is necessary, everyone is gonna need some CEUs and add a national pulse calibration test to the boards, right? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 5, 2004 Report Share Posted April 5, 2004 Todd- >I used to feel this way and we have discussed it here at length. Yet the NIH >keeps approving OM studies, none of which address this issue. And in >critiques of studies already done, this concern is also rarely >heard. I believe >eventually this critique will be raised as the opposition keeps moving the >goalposts. But it does not seem an impediment to getting funding or >acceptance of study results at the current time. While it may be true that not speaking to inter-rater reliability is not an impediment to getting funding by the NIH, it is an impediment to getting an understanding of the reality of pattern discrimination. And unless we start to make headway in demonstrating the veracity of pattern differentiation, we will not be saying much about TCM as TCM, but only making claims about the ability of acupuncture or herbs to change patient complaints and/or their lab values. >Ironically, this should be a much larger concern than the sham issue. I think >part of the reason no one is touching this issue yet is because so >little of the >subjective aspect of WM is inter-rater reliable. WM sidesteps this issue to >some extent by moving more and more away from subjective assessment as a >basis of dx. Yet subjective assessment remains vital to WM practice and no >one wants to raise theissue of how often doctors are wrong. Unless we also >plan to make this move towards diagnostic objectivity, we will have to >inevitably address this matter. Personally, I consider tongue dx to be pretty >objective as long as paramaters are predefined. It is pretty easy to agree on >what you see as long as people aren't colorblind. It is really the >pulse alone >that presents a challenge in modern TCM dx. This maybe true, in the fact that there is currently little inter-rater reliability, but maybe that is because there is no standard terminology, as Bob Flaws likes to point out. Maybe in training people using fewer variables of pulse, using standard terminology, could lead to greater reliability. Has this been studied well by people yet? Maybe it wouldn't be so hard to do. Assess inter-rater reliability before hand, then train and calibrate the px, and assess their reliability again. -Steve -- Stephen Bonzak <smb021169 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 5, 2004 Report Share Posted April 5, 2004 There needs to be evidence that every clinical observation that is a study variable but is not supported by exclusionary tests and standard measures can be reported reliably by the assessors. >>>>>>The next step will be to study these signs to see if they actually correlate to clinical ideas, i.e., do they really mean what they are said to Alon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 6, 2004 Report Share Posted April 6, 2004 At 7:12 PM +0000 4/5/04, wrote: >WM sidesteps this issue to >some extent by moving more and more away from subjective assessment as a >basis of dx. Yet subjective assessment remains vital to WM practice and no >one wants to raise theissue of how often doctors are wrong. Unless we also >plan to make this move towards diagnostic objectivity, we will have to >inevitably address this matter. Personally, I consider tongue dx to be pretty >objective as long as paramaters are predefined. It is pretty easy to agree on >what you see as long as people aren't colorblind. It is really the >pulse alone >that presents a challenge in modern TCM dx. -- I feel this debate has strayed prematurely (yet again) into the dichotomy of objectivity v subjectivity with regard to pulse diagnosis. If students are poorly trained, by teachers who are unable or unwilling to train them well, we can't even know whether subjectivity is a real issue in inter-rater unreliability. Here's a story: Eighteen months ago I went with a group to Nanchang for a two week program. One of our professors was a highly respected expert on the SHL/JGYL, and was also recognized as a pulse " master " . I was able to spend one morning with him in clinic, during which time we saw about 40 patients. I recorded my pulse findings for every patient I could, about 20 of them. We were told the professor's pulse findings in every case, and my identification of qualities agreed with his in every case; ie 100%. This professor was trained in a distant place, by teachers who have no common heritage with any teachers I have had, as far as I could tell, other than the literature and standards of the tradition in general. About the only other thing we have in common is that we have both been diligent in furthering our skills and knowledge; he more so than I, I dare say. Rory -- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 6, 2004 Report Share Posted April 6, 2004 At 7:12 PM +0000 4/5/04, wrote: >You show ten cardiologists the same EKG and you get some honest differences >of opinion, but it is also clear that they are looking at the same >thing. Lines >of differing length on a graph. On the other hand, it is often just >as clear to >me that my interns are not sensing what I sense (and not that I am necessarily >right, but just that agreement on tactile stimuli has proven very unreliable >compared to visual in perception studies). But if one person says choppy and >another says slippery, the image in each mind is quite different. >It is if they >are looking at different EKG's. This is quite different than two >people saying >slippery and still coming up with a different dx based upon differing >experience with pattern differentiation. At least they are " looking " at the >same thing. > >Since this type of inter-rater reliability requires calibration before a study >(while tongue and questioning only require defined parameters, IMO), the >question would immediately be raised after a study as to why one should trust >an uncalibrated practitioner. In other words, if only a calibrated researcher >can make a reliable dx, then that discredits most acupuncturists in >practice if >they cannot make the required dx w/o calibration. could be a windfall for >>pulse workshops. :-) -- As happy as I'd be if there was greater demand for pulse workshops, this is not where the problem needs to be addressed. Standards issues can only be addressed in the US schools of CM, in the basic training of practitioners. Once practitioners are graduated and licensed, the opportunity to set a professional standard is lost, except for the tiny minority who decide to study further. The profession in the US is largely made up of people with other priorities and interests than becoming competent pulse takers. Making a reliable diagnosis requires much more than the ability to skillfully observe, palpate, listen/smell, and question. Those are simply the ways in which we gather information. Good diagnosis requires knowledge of medicine and of life, and experience. This is often where the differences lie in diagnosis between different practitioners. Even with your analogy of the EKG, the nurse, the GP, and the experienced cardiologist, all of whom are trained to read EKGs, bring very different levels of knowledge and experience to their reading, and therefore often different conclusions. Even in the absence of the patient, and other data about the patient, the cardiologist will know things that the others won't; they will see relationships the others miss. Likewise with pulse, or any other method: an experienced and more expert practitioner will feel and and be able to interpret sensations and relationships in the reading that others don't even notice. There are several people on this list (maybe including you, Todd), who supervise clinic. My question for those of you do is, can your students reliably identify pulse qualities during their training? if not, why not? and what are you going to do about it? Rory -- At 7:12 PM +0000 4/5/04, wrote: >You show ten cardiologists the same EKG and you get some honest differences >of opinion, but it is also clear that they are looking at the same >thing. Lines >of differing length on a graph. On the other hand, it is often just >as clear to >me that my interns are not sensing what I sense (and not that I am necessarily >right, but just that agreement on tactile stimuli has proven very unreliable >compared to visual in perception studies). But if one person says choppy and >another says slippery, the image in each mind is quite different. >It is if they >are looking at different EKG's. This is quite different than two >people saying >slippery and still coming up with a different dx based upon differing >experience with pattern differentiation. At least they are " looking " at the >same thing. > >Since this type of inter-rater reliability requires calibration before a study >(while tongue and questioning only require defined parameters, IMO), the >question would immediately be raised after a study as to why one should trust >an uncalibrated practitioner. In other words, if only a calibrated researcher >can make a reliable dx, then that discredits most acupuncturists in >practice if >they cannot make the required dx w/o calibration. could be a windfall for >>pulse workshops. :-) -- As happy as I'd be if there was greater demand for pulse workshops, this is not where the problem needs to be addressed. Standards issues can only be addressed in the US schools of CM, in the basic training of practitioners. Once practitioners are graduated and licensed, the opportunity to set a professional standard is lost, except for the tiny minority who decide to study further. The profession in the US is largely made up of people with other priorities and interests than becoming competent pulse takers. Making a reliable diagnosis requires much more than the ability to skillfully observe, palpate, listen/smell, and question. Those are simply the ways in which we gather information. Good diagnosis requires knowledge of medicine and of life, and experience. This is often where the differences lie in diagnosis between different practitioners. Even with your analogy of the EKG, the nurse, the GP, and the experienced cardiologist, all of whom are trained to read EKGs, bring very different levels of knowledge and experience to their reading, and therefore often different conclusions. Even in the absence of the patient, and other data about the patient, the cardiologist will know things that the others won't; they will see relationships the others miss. Likewise with pulse, or any other method: an experienced and more expert practitioner will feel and and be able to interpret sensations and relationships in the reading that others don't even notice. There are several people on this list (maybe including you, Todd), who supervise clinic. My question for those of you do is, can your students reliably identify pulse qualities during their training? if not, why not? and what are you going to do about it? Rory -- -- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 6, 2004 Report Share Posted April 6, 2004 At 3:47 PM -0500 4/5/04, Stephen Bonzak wrote: >Maybe in training people using fewer variables of pulse, using standard >terminology, could lead to greater reliability. -- Stephen, You bring up an important point. In my view the basic set of variables we should train students to reliably identify are: - rate - rhythm - depth - width - force - hardness These variables account for all the pulses of most patients. They completely account for 18 of the 27 standard qualities. Even if students were unable to identify the standard qualities, if they understood the interpretation of these variables they could make an adequate diagnosis. The remaining 9 qualities, including slippery and choppy, and most of which are uncommon, have very distinctive features in addition to the variables above that make them relatively easy to identify by well trained students, in my experience. Of course, this last point is where we come to the crux of the matter. The quality of training in pulse diagnosis amongst, and even within, US CM schools is highly variable, and for the most part dismal. From what I've witnessed, clinical faculty often abdicate their responsibility for ensuring that students can properly identify pulses. There are several factors that seem to play into this situation: - time pressures created by high student & patient per supervisor ratios - poorly trained supervisors who cannot reliably identify pulses themselves, so obviously can't teach students - inappropriate attitudes among supervisors such as the discounting of the value of pulse diagnosis - laziness of supervisors unwilling to check every patient's pulse against student's findings Rory -- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2004 Report Share Posted April 7, 2004 , Rory Kerr <rorykerr@o...> wrote: > > There are several people on this list (maybe including you, Todd), > who supervise clinic. My question for those of you do is, can your > students reliably identify pulse qualities during their training? if > not, why not? and what are you going to do about it? It is an extremely tricky matter. PCOM is huge with 400 students just in SD and over 70 faculty. I don't teach intro dx classes, so by the time students arrive in clinic, they have already been indoctrinated in some teacher's idiosyncracies on this matter. It is impossible for me to recalibrate the students in clinic as they often grant more authority to whatever teacher first taught them the material. this is understandable as I don't put myself out as a pulsemaster, while many others do make that claim for themselves. It is my position that clinic must be the hub of one's training. all academics must feed into this hub like spokes on a wheel. the academic instructors MUST take their cues from the clinical supervisors. It is absolutely ludicrous to be trained in pulse by teachers who do no formal clinical supervision in the school clinic. the only solution I see is to make sure that teachers are calibrating students to some clinical standard. But this necessarily means selecting a single approach and setting others aside. This means some supervisors will have to conform to something other than what they learned. and of course this all makes a very strong case against eclectic education. If you have too many conflicting influences, you end up learning nothing with confidence. I know what people are thinking as they read this. that I am arguing for enforced controls on TCM practice. Not at all. do as you please. Let the market and research sort it out. I am talking merely about education and clinical training for beginners. Anyone who thinks CM can be presented to students with all its unresolved contradictions from day one and result in anything but confusion has never done much teaching. Once calibrated and standardized, people can go off in any direction they please, but now possessed of a common language and confident in their diagnostic reliability. Rampant eclecticism and MSU only lead to an lack of confidence, endemic in recent grads. Ironically, japanese acupuncture, which is often appealing to those who reject TCM as rigid and dogmatic, is actually far more calibrated and standardized in the training mode. If you don't feel the same thing in pulse and abdomen as your teacher every time, you will never get anywhere in the world of meridian acupuncture. While there is this myth that chinese docs easily embrace contradiction and unresolved conflicts, I have not found this to be the case. My chinese colleagues are actually more likely to embrace their own style ofpractice and vehemently reject all other contradictory ideas. I think the plurality of practice across chinese culture as a whole has been confused with the practice of individuals. I do not find the typical chinese doc to be pluralistic at all. And I have no doubt that it is the least eclectic and most focused px who get the best results. So while I have no problem with 100 schools teaching 100 different styles, I think each school should likewise focus narrowly. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2004 Report Share Posted April 7, 2004 At 6:08 PM +0000 4/7/04, wrote: >I don't teach intro dx classes, so by the time students >arrive in clinic, they have already been indoctrinated in some teacher's >idiosyncracies on this matter. It is impossible for me to recalibrate the >students in clinic as they often grant more authority to whatever teacher >first taught them the material. this is understandable as I don't put myself >out as a pulsemaster, while many others do make that claim for themselves. -- Thanks for your response. Please forgive me for commenting on your personal situation, but I do so to illustrate a point. On the issue of authority, and I wouldn't be too interested in who the students grant authority to. While a student is under your supervision, (and operating under your license), he or she is obliged to follow your requirements. The 27/28 qualities are a well established standard in all systems of Chinese medicine that I know of, so to require a student to report their findings in those terms is completely within bounds, regardless of what they might have previously been taught. In fact, to not require this is to abdicate a teaching responsibility, and is the reason so many practitioners leave school not knowing their pulses, which is what we started out complaining about. That's not to say they can't learn other methods, but the basic qualities are just that, basic...and essential. The solution to this is in our hands, both literally and figuratively. Rory -- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2004 Report Share Posted April 7, 2004 , Rory Kerr <rorykerr@o...> wrote: The 27/28 qualities are a well > established standard in all systems of Chinese medicine that I know > of, so to require a student to report their findings in those terms > is completely within bounds, regardless of what they might have > previously been taught. In fact, to not require this is to abdicate a > teaching responsibility, and is the reason so many practitioners > leave school not knowing their pulses I think perhaps I have not been clear. Students do indeed learn the textbook definitions of the 28 pulses. that is not the issue at PCOM. It is that certain pulses have to be felt under supervision, not just decribed. Unless you feel the wiry pulse under my supervision, you can have no idea what I am feeling when I use the label wiry. Fast, slow, superficial, deep, irregular, no problem, but wiry, slippery and choppy are another ballgame, IMO. the problem arises when other teachers have told students as they are feeling pulse that this one is choppy and this other one is slippery. the students learn to associate the feelings under their fingers with the label the teacher gives it. If I do not agree with another teacher about which feeling gets which label, I do not see how I can convince the student that I am right. the fact is that I don't really know that I am right and others are wrong. Ionly know that I was calibrated differently than my colleagues. so unless we all have a priori agreement about what certain pulses feel like, not just their textbook description, I do not think calibration can be achieved. On my clinic shifts, I do have the last word and my decisions determine the finaldx. However, the issue in my mind was not so much practice or even education, per se, but rather how to do a research study and then generalize the results to a population that does not all see the same pulse with the same eyes, so to speak. Only if we are all calibrated to feel the same things, like cardiologists are calibrated to hear the same heart sounds, would research results ever be really meaningful. An even bigger part of the issue may be how people organize all the collected data to come up with a dx. In fact, I see my main duty in clinic is to teach students to sort the wheat from the chaff. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 At 5:16 AM +0000 4/8/04, wrote: >Students do indeed learn the textbook >definitions of the 28 pulses. that is not the issue at PCOM. It is >that certain >pulses have to be felt under supervision, not just decribed. Unless you feel >the wiry pulse under my supervision, you can have no idea what I am feeling >when I use the label wiry. Fast, slow, superficial, deep, >irregular, no problem, >but wiry, slippery and choppy are another ballgame, IMO. the problem arises >when other teachers have told students as they are feeling pulse that this one >is choppy and this other one is slippery. the students learn to associate the >feelings under their fingers with the label the teacher gives it. If I do not >agree with another teacher about which feeling gets which label, I do not see >how I can convince the student that I am right. the fact is that I >don't really >know that I am right and others are wrong. Ionly know that I was calibrated >differently than my colleagues. > >so unless we all have a priori agreement about what certain pulses feel like, >not just their textbook description, I do not think calibration can >be achieved. -- Thanks for clarifying. I guess one solution for the situation you describe would be for the clinical faculty to get together every so often, maybe in small groups, to take pulses and compare results and see where the consistent differences are. Without even trying to change anyone's opinion, I think such a process would tend to create normalization. It would also allow you all to know whether it's necessary to do more to create agreement. Rory -- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 Rory et al., In my reading of history and my experience of practicing Chinese medicine in N. America, Europe, and China, the problem of inter-rater reliability has been a long-term, on-going problem in Chinese medicine. I believe that it is a problem that we must address and find some solution for if we are ever going to become a real medical profession in the modern world. Even in China, this is a problem. This is why the Ministry of Health published national Chinese medical standards for disease diagnosis and pattern discrimination several years ago. I believe that we have to adopt some standards even though those standards can never be completely adequate or wholy satisfactory. Everything in life is a trade-off. Nothing is perfect. Every tool has its limitations. As long as we are clear about that and maintain some method for allowing " wiggle room, " then adopting standards should not be seen as a bad thing. It is part of the process of growing up, i.e., making compromises in an imperfect world. Until we adopt some kinds of standards, teaching and studying are difficult, clinical research is difficult, intraprofessional communication is difficult, referral is difficult, and peer review is difficult. Therefore, third party payment is/may be difficult. When it comes to pulse images, there are only two I can think of which must simply be pointed out in clinical practice: 1) the slippery pulse (hua mai) and 2) the stringlike-bowstring-wiry pulse (xian mai). Then there are another few where there are real, substantative differences in interpretation of the standard definitions: 1) short pulse (duan mai), 2) long pulse (chang mai), 3) dissipated-scattered pulse (san mai), and 4) surging pulse (hong mai) are the ones that come immediately to mind. In these four cases, there are different historical schools of thought within the Chinese medical literature which have never been completely reconciled. The problem in these cases is that the classical definitions are tactiley ambiguous and open to differences in interpretation. However, if one knows that there are differences of thought on the interpretation of these pulse images' definitions, then, in discourse, one can say something like, " I believe this is the scattered pulse, meaning that it is floating and wide with no palpable edges as opposed to its being floating, wide, and irregular in beat when pressed. " In this case, one has simply stated which of the two existing definitions they are using. This is similar to using Wiseman's standard terminology but then diverging from it in certain specified and commented upon instances. There are also a couple/few pulses which have two different definitions depending on whether one is using the term to describe healthy or unhealthly aspects of the pulse. For instance, the moderate pulse (huan mai) means not rapid and not bowstring or tight when used to describe a healthy pulse, but means slightly slow when used to describe an unhealthy pulse. Similarly, the vacuous pulse may mean any pulse which tends to be fine and forceless in a general, ballpark sense, or it may be the proper name of an individual pulse image, in which case it means a pulse that is floating, large or wide, and foreceless. As for the rough-choppy pulse (se mai), I don't think that pulse is ambiguous at all, nor do I think it necessarily has to be pointed out in clinic. If one accepts that choppy or rough is a synonym for the 3-5 pulse, then this pulse is one that speeds up and slows down with the breathing and is knowable simply by counting its beats rhythmically. While standards have their inherent problems and limitations, there is a way to work with standards so that they do not become overly rigid and inflexible. Once one understands that, then there is really nothing to be scared about when adopting and using standards. As many philosophers have demonstrated, rules and standards are not the antithesis of freedom. Rules and standards are only the antithesis of caprice, and capriciousness is usually associated with immaturity and foolishness. Bob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 , " Bob Flaws " < pemachophel2001> wrote: > > As for the rough-choppy pulse (se mai), I don't think that pulse is ambiguous at all, nor do I think it necessarily has to be pointed out > in clinic. and yet of the commonly felt pulses, this one seems to give students the most difficulty. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 Bob- >In my reading of history and my experience of practicing Chinese >medicine in N. America, Europe, and China, the problem of >inter-rater reliability has been a long-term, on-going problem in >Chinese medicine. I believe that it is a problem that we must address >and find some solution for if we are ever going to become a real >medical profession in the modern world. Even in China, this is a >problem. This is why the Ministry of Health published national >Chinese medical standards for disease diagnosis and pattern >discrimination several years ago. I believe that we have to adopt >some standards even though those standards can never be >completely adequate or wholy satisfactory. Do you have access to these standards or know where I can find them? -Steve -- Stephen Bonzak <smb021169 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 Yeah, because the teachers are confused about it. Bob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 The only thing that works for me to teach my students is to show with my hands, the different qualities. (The top edge of my first finger hitting a downward facing palm for wiry, the whole dorsum of my hand gliding under the palm for slippery, my knuckles creating choppy, making a hole with my fingers to show thready/thin etc...) I don't know either if I am " calibrated " with my fellow teachers, but at least my students know what I, me, see as the different qualities. Referring to any book will just create confusion with clarification from each teacher. doug , Rory Kerr <rorykerr@o...> wrote: > At 5:16 AM +0000 4/8/04, wrote: > >Students do indeed learn the textbook > >definitions of the 28 pulses. that is not the issue at PCOM. It is > >that certain > >pulses have to be felt under supervision, not just decribed. Unless you feel > >the wiry pulse under my supervision, you can have no idea what I am feeling > >when I use the label wiry. Fast, slow, superficial, deep, > >irregular, no problem, > >but wiry, slippery and choppy are another ballgame, IMO. the problem arises > >when other teachers have told students as they are feeling pulse that this one > >is choppy and this other one is slippery. the students learn to associate the > >feelings under their fingers with the label the teacher gives it. If I do not > >agree with another teacher about which feeling gets which label, I do not see > >how I can convince the student that I am right. the fact is that I > >don't really > >know that I am right and others are wrong. Ionly know that I was calibrated > >differently than my colleagues. > > > >so unless we all have a priori agreement about what certain pulses feel like, > >not just their textbook description, I do not think calibration can > >be achieved. > -- > > > > Thanks for clarifying. I guess one solution for the situation you > describe would be for the clinical faculty to get together every so > often, maybe in small groups, to take pulses and compare results and > see where the consistent differences are. Without even trying to > change anyone's opinion, I think such a process would tend to create > normalization. It would also allow you all to know whether it's > necessary to do more to create agreement. > > Rory > -- > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 Rory, What a simple, common sense suggestion! But I can't see it happening at any schools that I am aware of. If it did, I think we'd see that, in many case, the emperor has no clothes. Bob Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 8, 2004 Report Share Posted April 8, 2004 An interesting positive study on Glucosamine CME Glucosamine Has a Disease-Modifying Effect on Osteoarthritis http://mp.medscape.com/cgi-bin1/DM/y/ef4s0EDHzl0DzC0Fudk0A5 Alon Quote Link to comment Share on other sites More sharing options...
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