research can't be done?

[Guest guest]

The main cogent objection I hear to doing research on TCM is that

research that embraces our model of individual treatments cannot be

done. However that is a complete falsehood. One could easily match

three groups of patients, do individualized therapy on one, tailored

therapy on the other and standard proven treatment on the third, like

Benssousan's IBS study. The tailored group could even be allowed to

have complete individualization with no restrictions and you could

still get an accurate comparison. this would not prove how well TCM

compares to placebo, but it would say how it compares to whatever is

currently being done by WM. This rational analysis could be done with

anything from tuning forks to five element. If the endpoint is

supposed to be better health, there is a way to measure it. Such

studies would instantly validate the method. I don't see the concern.

There is only one possible reason for resistance, likely an unconscious

one. In the absence of science, all many people have to keep them

promoting acupuncture is faith. Faith is always hard to keep up,

especially in modernity, so in the back of the minds of most magical

thinkers, there is always some shred of doubt. Evidence allays doubt

and thus allays fear. Fear that that the multicultural view extended

to acupuncture will fail just as miserably as it fails in the world at

large. That some ways of doing things will be shown to be better than

others. and some things may fall by the wayside. Not acupuncture

itself, but some of the cults that have sprung up around it in the past

500 years. I don't understand why people can't see that a world based

upon magic is a world where fears can easily be manipulated by the

powerful. Only the light of rational thought, as embraced by the

founders, cuts through this darkness. That's why that era was called

the enlightenment.

 

 

Chinese Herbs

 

 

FAX:

 

 

[Guest guest]

On 15/06/2004, at 2:35 AM, wrote:

 

> The main cogent objection I hear to doing research on TCM is that

> research that embraces our model of individual treatments cannot be

> done. However that is a complete falsehood. One could easily match

> three groups of patients, do individualized therapy on one, tailored

> therapy on the other and standard proven treatment on the third, like

> Benssousan's IBS study.

 

I agree research evaluating the value or irrelevance of individualized

treatments " can " be done to test TCM as it is practiced. I believe the

problem may be obtaining sufficient numbers of subjects to obtain

statistically significant results. Certainly, this difficulty leaves

the research open to those who are looking for an excuse to attack such

research and dismiss the results.

 

I would be interested to here your view on what " disease " or

" condition " would be best for such studies. That is; TCM disease

categories or modern western diseases?

 

Certainly, studies designed to evalute TCM treatment for " western

disease " would be of more value for producing EBM arguments to the

general medical community; but would this really be testing TCM? What I

mean is, although western disease differentiation in TCM is prominent

now, it also has a much shorter history of application and experience.

Perhaps evaluating the more " time-tested " TCM diseases and their

individualized approaches would produce more accurate and meaningful

results for evaluating TCM efficacy?

 

Best Wishes,

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

I'm not at all sure that individualized prescriptions are the de facto

norm within this profession. I think we might want to determine that

before making any assumptions about research design. No sense

researching something which, in fact, is the standard of care (whether

we like it or not).

 

Bob

[Guest guest]

Hmm,

 

I am not sure what you mean here Bob; is treatment based on syndrome

differentiation different from individulized prescriptions? If these

are basically the same thing, they may not be the de facto norm in our

profession; but they should be shouldn't they?

 

Steve

 

On 16/06/2004, at 4:58 AM, Bob Flaws wrote:

 

> I'm not at all sure that individualized prescriptions are the de facto

> norm within this profession. I think we might want to determine that

> before making any assumptions about research design. No sense

> researching something which, in fact, is the standard of care (whether

> we like it or not).

>

> Bob

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

Steve,

 

Individualized treatment in terms of CM may mean two things to my mind:

 

1. Treatment based on individual pattern presentation

 

2. Individual customization of patient's Rx

 

" Should " and " is " are also two different things. When I said " de facto

standard of care, " I meant what the majority of practitioners in the

U.S./North America actually do. I am reasonably sure than the de facto

SOC for CM herbs in the U.S. is not number 2 above and may not even be

number 1. Since most practitioners prescribe ready-made CM medicinals

which are hard to modify other than prescribing multiple remedies

simultaneously, most are not individually customizing patient

prescriptions. In addition, many practitioners (based on what we hear

in terms of customer questions) prescribe primarily on the basis of

disease diagnosis and not necessarily or primarily on the basis of

pattern discrimination. So I was just pointing out that some of the

assumptions of CHA members about CM SOC in North America may not be

accurate. Part of the problem, in fact, is that we really do not know

conclusively what the rank and file are doing.

 

Bob

[Guest guest]

Bob,

 

I see what you mean, and I agree with the reality of this unfortunate

situation.

 

As far as the EBM research topic of this thread goes; I think we should

not lower the standards of study design due to the generally poor

application of TCM protocols in our profession. Research needs to study

the most professionally appropriate and respected practices before we

simplify our standards to reflect the " ma ma hu hu " doctors out there.

 

To me, and I am sure you will agree on this; the professional standard

of care is individual treatment based on pattern discrimination (which

I mean to include points 1 AND 2 of your definition). So meaningful

research must incorporate this; otherwise we are just testing the

lowest common denominator in our profession. I believe this approach

could be potentially disastrous in our pursuit of research based

recognition for our profession.

 

Best Wishes,

 

Steve

 

On 17/06/2004, at 12:46 AM, Bob Flaws wrote:

 

> Steve,

>

> Individualized treatment in terms of CM may mean two things to my mind:

>

> 1. Treatment based on individual pattern presentation

>

> 2. Individual customization of patient's Rx

>

> " Should " and " is " are also two different things. When I said " de facto

> standard of care, " I meant what the majority of practitioners in the

> U.S./North America actually do. I am reasonably sure than the de facto

> SOC for CM herbs in the U.S. is not number 2 above and may not even be

> number 1. Since most practitioners prescribe ready-made CM medicinals

> which are hard to modify other than prescribing multiple remedies

> simultaneously, most are not individually customizing patient

> prescriptions. In addition, many practitioners (based on what we hear

> in terms of customer questions) prescribe primarily on the basis of

> disease diagnosis and not necessarily or primarily on the basis of

> pattern discrimination. So I was just pointing out that some of the

> assumptions of CHA members about CM SOC in North America may not be

> accurate. Part of the problem, in fact, is that we really do not know

> conclusively what the rank and file are doing.

>

> Bob

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

So let me devil's advocate just a bit more.

 

We do research showing that individualization (1 & 2) works. The

medical establishment gets excited and starts referring patients to

their local practitioners in larger numbers. The rank and file don't

do what the research proved effective. Then what happens?

 

Bob

[Guest guest]

At 2:52 PM +0000 6/17/04, Bob Flaws wrote:

>We do research showing that individualization (1 & 2) works. The

>medical establishment gets excited and starts referring patients to

>their local practitioners in larger numbers. The rank and file don't

>do what the research proved effective. Then what happens?

--

Bob,

 

At least some TCM colleges have been training people to do

individualized prescribing for many years. For example, at Touro

College (NYC) individualized raw herb prescribing is the standard of

care. Back in the '80s, my training at Emperor's College was similar.

There are also many very well qualified Chinese practitioners. There

should be no shortage of practitioners qualified to practice this way.

 

But you are suggesting there is such a shortage. How do you come to

that conclusion?

 

Rory

--

 

 

 

[Guest guest]

, " Bob Flaws "

<pemachophel2001> wrote:

> So let me devil's advocate just a bit more.

>

> We do research showing that individualization (1 & 2) works. The

> medical establishment gets excited and starts referring patients to

> their local practitioners in larger numbers. The rank and file don't

> do what the research proved effective. Then what happens?

>

> Bob

 

 

Well, what happens when there are proven medical therapies and an MD

decides to violate the standards of care for capricious reasons?

With all due respect to Rory, I agree with Bob. There are very few

formula writers in our field. Of my last 500 students, maybe 10

still maintain raw herb pharmacies after a few years in practice.

 

[Guest guest]

By the typical questions our (and every other CM herb sellers')

customer service personnel are asked every day. It's quite frightening

sometimes. Also from the many, many resports from unsatisfied patients

of other practitioners.

 

Bob

[Guest guest]

Ahhh.......devils advocates ask such difficult questions!!!

 

Seriously, as professionals, we SHOULD uphold a very specialized

knowledge and high degree of proficiency in our domain; however this is

the ideal situation not human reality.

 

I had approximately 23 classmates graduate with me; I would refer

patients to 1 or 2. This is the sad reality; and I am sure it is no

different in any profession.

 

All WM doctors are not life-long learners or practice the appropriate

SOC either; Arapax is contraindicated for use in children and teenagers

here in Australia (I believe it is banned in UK and USA) and should be

common knowledge throughout the WM community by now. However, a study

has just found that 24,000 prescriptions were given to children in the

past 12 months!!! (Australia's population is only 21mil.)

 

The medical establishment has the power, but is no more professional

than us.

 

What are we to do about the low quality of practice of some of our

peers? That is up to those who teach and regulate our profession to

ensure graduates are actually competent and willing life-long learners.

 

Sadly, too many see TCM as a business rather than a career and see

" best practices " and a professional " SOC " as contraindicated to making

money efficiently. It frustrates me to no end that medicine, both

eastern and western contains these individuals; but I can't personally

throw them out on their ear.

 

So, I suppose I believe that good research will increase awareness of

the " potential " of TCM and assist in public education. Finding a

professional practitioner will remain " pot-luck " until education and

regulation are sorted out.

 

Best Wishes,

 

Steve

 

On 18/06/2004, at 12:52 AM, Bob Flaws wrote:

 

> So let me devil's advocate just a bit more.

>

> We do research showing that individualization (1 & 2) works. The

> medical establishment gets excited and starts referring patients to

> their local practitioners in larger numbers. The rank and file don't

> do what the research proved effective. Then what happens?

>

> Bob

>

 

 

Dr. Steven J Slater

Practitioner and Acupuncturist

Mobile: 0418 343 545

chinese_medicine

[Guest guest]

Rory,

 

I'm a practitioner in Denver, Colorado (same state as Bob Flaws), and,

unfortunately, in this state, tailored bulk decoctions are not the standard.

It's difficult for me to say why this is. I'm a little embarasssed to say this

and would very much like to change it, as I think we are failing to put our

'best foot forward' to the public.

 

--- John Aguilar Jr., L.Ac.

 

Rory Kerr <rorykerr wrote:

At 2:52 PM +0000 6/17/04, Bob Flaws wrote:

>We do research showing that individualization (1 & 2) works. The

>medical establishment gets excited and starts referring patients to

>their local practitioners in larger numbers. The rank and file don't

>do what the research proved effective. Then what happens?

--

Bob,

 

At least some TCM colleges have been training people to do

individualized prescribing for many years. For example, at Touro

College (NYC) individualized raw herb prescribing is the standard of

care. Back in the '80s, my training at Emperor's College was similar.

There are also many very well qualified Chinese practitioners. There

should be no shortage of practitioners qualified to practice this way.

 

But you are suggesting there is such a shortage. How do you come to

that conclusion?

 

Rory

--

 

 

 

[Guest guest]

At 9:33 PM +0000 6/17/04, .geo wrote:

>There are very few

>formula writers in our field. Of my last 500 students, maybe 10

>still maintain raw herb pharmacies after a few years in practice.

--

 

You and Bob may well be right, but it would be interesting to do a

careful survey to find out. How about starting with a survey of the >

900 CHA list members. Of course, there are also a lot of East Asian

practitioners to consider as well.

 

Rory

--

 

 

 

[Guest guest]

Bob's comments hit two nerves for me:

 

(1) After 20 years of practice, there is absolutely no doubt in my mind that

individualization works, and I try to drum this into all my students with

homework and exercises that require that they know how to assess multiple

syndromes/patterns and tailor herbal formulas to such. I was astounded to find

that no one on several herb discussion lists could come up with a single

research reference that demonstrates this. Almost all of the Chinese research

(in so-called TCM journals) typically studies the results of a Chinese herb or

herbal formula for some western-defined disease, and the statistics lump all

experimental subjects into one group without differentiation according to

patterns. Most of this research carries very little information value for me,

and I find myself becoming weary to discover yet more of it.

 

The method for doing the research properly can vary in sophistication. The

simplest method from experimental-design and mathematical perspectives, is to

break the population of subjects with a specific medical condition into

sub-groups or clusters, each cluster having a well-defined predominant TCM

syndrome/pattern or patterns in common. (The assessment of patterns should be

done by a panel of skilled diagnosticians who can justify their assessment with

an explicit breakdown of the reasoning and a magnitude estimate of the pattern

severity for each subject.) 50% of the subjects in each cluster should be

assigned, double-blind, to a control group receiving placebo. All experimental

(non-control) subjects within a cluster would receive the same formula,

optimized for the average or typical characteristics of that cluster.

 

A more complex method that would yield significantly more information would be

to analyze each subject individually, determining a numerical vector-space

estimate of their state of health. Combined with herbal action vectors, one

could use multi-variate cross-correlation to determine the relative

effectiveness of a strategy for specific regions of the vector subspace.

I've been working on such methods to aid in the detection of environmental and

occupational health effects, and such could be adapted to the study of Chinese

herbs as well.

 

 

(2) The other major problem is that the " rank and file " will continue to merrily

choose herbs based on medical criteria - this formula for that illness,

regardless of what the research proves.

 

Years ago I had a client with cancer who moved to a distant city. This was

before the days of the Internet, and I did not know of anyone in that city, so I

suggested the former client contact the NCCAOM for certified Chinese herbalists.

He found 4 names, contacted each acupuncturist/herbalist, and in every single

case, these people offered to provide a " very effective formula for cancer "

without doing an individualized TCM assessment or even taking much of a case

history.

 

What is needed is a certification system that thoroughly tests practitioners'

skills in complex analysis ( " diagnosis " ), providing a means to let the general

public know that a specific practitioner is **capable** of exercising skill and

intelligence in this area. (Whether or not the practitioner chooses to become

lazy or sloppy is another matter.) I do not believe that current official

certification exams adequately test this ability, and that is a major part of

the problem. Simplistic multiple choice exams are better designed for preparing

people to appear on TV quiz shows ( " Herbs of Fortune " ?) - they do not simulate

the types of analytical problems that one faces every day in the clinic.

 

The " TCM Herbal Tutor " software, that we now require our own students to use,

gives users practice in assessing syndromes based on limited information. The

problems simulate the types of difficulties a practitioner will face in taking a

case history and analyzing it. We've found that most acupuncturists cannot do

these basic exercises and require extensive training to do them well, in spite

of having had years of schooling. (Todd will be demo-ing this software at the

conference in San Diego this weekend.)

 

 

I'll repeat my appeal that acupuncture needs to be considered and certified

separately from herbology. One of the reasons there are so few skilled

herbalists, is that many TCM schools teach it only as an afterthought. If the

acupuncturists do not wish to devote the time required to learn herbology well,

they should move over and let someone else do the job:

http://www.rmhiherbal.org/review/2004-2.html

 

 

---Roger Wicke, PhD, TCM Clinical Herbalist

contact: www.rmhiherbal.org/contact/

Rocky Mountain Herbal Institute, Hot Springs, Montana USA

Clinical herbology training programs - www.rmhiherbal.org

 

 

 

 

> Thu, 17 Jun 2004 14:52:59 -0000

> " Bob Flaws " <pemachophel2001

>Re: research can't be done?

>

>So let me devil's advocate just a bit more.

>

>We do research showing that individualization (1 & 2) works. The

>medical establishment gets excited and starts referring patients to

>their local practitioners in larger numbers. The rank and file don't

>do what the research proved effective. Then what happens?

 

 

 

---Roger Wicke, PhD, TCM Clinical Herbalist

contact: www.rmhiherbal.org/contact/

Rocky Mountain Herbal Institute, Hot Springs, Montana USA

Clinical herbology training programs - www.rmhiherbal.org

[Guest guest]

Roger,

 

I agree with you that acupuncture and Chinese herbology should be

educated, tested, and licensed separately, but that ain't gonna

happen, not any time in the forseeable future in any state in the U.S.

That's a " no-start " position politically. I also do not see the

schools radically changing their modus operandi and upgrading

academically. I believe that the schools as currently constituted and

operated are the perpetuators (but not necessarily the originators) of

many of the problems within our profession. However, the schools are

also only responding to certain demands and realtities in the

marketplace. As long as they can continue filling their enrollment

without making radical changes, they won't. Economics 101.

 

BTW, I'm reading Asimov's Foundation Trilogy based on your

recommendation. Fun reading. Thanks for the recommendation, but I'm

not sure I would agree that the story models universal truths about

the rise and fall of cultures. In fact, the more I think about it, the

less I see the downfall of the Roman Empire and the subsequent history

of the Western world as emblematic of some uber-cycle. This is

probably off topic. Sorry, Todd.

 

Bob

[Guest guest]

, " Bob Flaws " <pemachophel2001>

wrote:

 

This is

> probably off topic. Sorry, Todd.

 

Asimov is a long time favorite, so I'll cut you some slack. See you later

today. BTW, Bob's

keynote lecture at CHA tonight is open free to all as are our vendor halls all

weekend. We

also have other free lectures during the weekend, including ones by Honora Wolfe

and

Andy Gaederrt. So if you live in Socal, please stop by. Beer, wine, liquor,

coffee, tea and

soft drinks will be available.

 

[Guest guest]

Bob,

 

What I am proposing is actually administratively quite simple, and it does not

depend upon any permission or approval from any state agency or licensing board,

nor any agreement by TCM colleges - these can all go their merry way with

business as usual. It is based more on the model of many commercial certifying

agencies, such as Underwriters Labs for electrical equipment - a **voluntary

standard** that companies can receive for a product if it meets certain

standards. The public recognizes it as a " seal of quality " , and can choose to

buy it, nor not, as they wish.

 

Also based on Economics 101, there **is** a demand for certifiably competent

herbalists. I am constantly asked by people how one can tell whether an

" herbalist " is qualified, and I have to respond that anyone can claim to be an

herbalist, simply by self-declaration, or self-delusion. This makes it difficult

for the public to judge individual competence. The economics of the situation as

I see it is this: there is an unmet demand among a growing percentage of the

public - these people want qualified herbalists, but they also do not

necessarily support mandatory licensing, as indicated by the popularity of the

Health Freedom movement. Health Freedom acts specify what many people want -

they want to be able to choose to patronize practitioners of their choice,

whether licensed or unlicensed, but they also want the practitioners to be under

obligation to accurately state their education and qualifications. My proposal

is to simply provide the public with an objective means for indicating TCM

herbalist competence in complex assessment skills. I know the demand is there,

as I get a constant stream of website inquiries for people all over N. America

for referals to graduates of our programs. It is the TCM profession itself that

is resistant to this, and again, according to principles of economics, when

professional monopolies enforce a situation in spite of an unmet economic

demand, something will eventually give or break. In the worst case, the TCM

profession will lose its credibility with respect to herbology, and other groups

will take it over.

 

The American Herbalists Guild already has a TCM herbology certification option,

as they have correctly recognized that there is a growing demand for Chinese

herbology as such, independent of acupuncture. However, the AHG certification

standards are based on subjective criteria, interviews, peer review, and not on

objective skills evaluation. All I am proposing to do the same job the AHG is

already doing, but do it better and more objectively.

 

I agree with you that the majority of the profession, licensing boards, and the

TCM schools are part of the problem and would not support such a proposal. Fine.

To work, their cooperation is not required or necessary. All it would require

initially is a minority of people within the profession who recognize the

problem and are willing to support a solution.

 

By the way, my main purpose in pointing out the Asimov books is that these

illustrate that when civilizations are in decline, as is ours by almost any

measure, problems do not get solved either by the majority or by

institutionalized bureaucracies - these latter are generally fated to

disintegrate of their own inertia and incompetence. Several major historians

emphasize this, including Arnold Toynbee and Carroll Quigley; their

contributions allow one to recognize when this is happening and avoid wasting

effort on futility. It is generally a small minority who recognizes the

situation and independently takes action to salvage what can be salvaged. But

this is rarely achieved by forcing the majority to go along. Instead, the

problem must be solved by isolating oneself from the dominant bureaucracies and

designing solutions that do not require their participation. This is exactly

what I am proposing. The alternative is to allow the situation to degenerate

further, to the point that little can be salvaged. We have a certain window of

opportunity here, and as you have correctly seen the problems, it would be

tragic not to attempt doing something about it.

 

 

 

---Roger Wicke, PhD, TCM Clinical Herbalist

contact: www.rmhiherbal.org/contact/

Rocky Mountain Herbal Institute, Hot Springs, Montana USA

Clinical herbology training programs - www.rmhiherbal.org

 

 

 

> " Bob Flaws " <pemachophel2001

>Re: research can't be done?

>

>Roger,

>

>I agree with you that acupuncture and Chinese herbology should be

>educated, tested, and licensed separately, but that ain't gonna

>happen, not any time in the forseeable future in any state in the U.S.

>That's a " no-start " position politically. I also do not see the

>schools radically changing their modus operandi and upgrading

>academically. I believe that the schools as currently constituted and

>operated are the perpetuators (but not necessarily the originators) of

>many of the problems within our profession. However, the schools are

>also only responding to certain demands and realtities in the

>marketplace. As long as they can continue filling their enrollment

>without making radical changes, they won't. Economics 101.

>

>BTW, I'm reading Asimov's Foundation Trilogy based on your

>recommendation. Fun reading. Thanks for the recommendation, but I'm

>not sure I would agree that the story models universal truths about

>the rise and fall of cultures. In fact, the more I think about it, the

>less I see the downfall of the Roman Empire and the subsequent history

>of the Western world as emblematic of some uber-cycle. This is

>probably off topic. Sorry, Todd.

 

---Roger Wicke, PhD, TCM Clinical Herbalist

contact: www.rmhiherbal.org/contact/

Rocky Mountain Herbal Institute, Hot Springs, Montana USA

Clinical herbology training programs - www.rmhiherbal.org

[Guest guest]

Roger,

 

" What I am proposing is actually administratively quite simple, and it

does not depend upon any permission or approval from any state agency

or licensing board, nor any agreement by TCM colleges - these can all

go their merry way with business as usual. It is based more on the

model of many commercial certifying agencies, such as Underwriters

Labs for electrical equipment - a **voluntary standard** that

companies can receive for a product if it meets certain standards. The

public recognizes it as a " seal of quality " , and can choose to buy it,

nor not, as they wish. "

 

The Chinese herb companies who are members of AHPA have discussed

exactly this possibility. However, I don't know where the discussion

is at the present time. The whole ephedras/banxia thing seems to have

taken precedence. But I agree that this is a good idea.

 

" The American Herbalists Guild already has a TCM herbology

certification option, as they have correctly recognized that there is

a growing demand for Chinese herbology as such, independent of

acupuncture. However, the AHG certification standards are based on

subjective criteria, interviews, peer review, and not on objective

skills evaluation. All I am proposing to do the same job the AHG is

already doing, but do it better and more objectively. "

 

OK, how do I get involved in this? I'm willing to give it a try.

 

Bob