Fwd: pulse simulator

[Guest guest]

When Roger Wicke first asked me to look at his pulse simulator, I was

admittedly skeptical. However students have been very enthusiastic. I

think it depends on how one learns. Storing images of palpated

sensations does not come easily to many. Thus graphical

representations of pulse images can be useful. they do not substitute

for palpation, but serve as a tool to orient oneself in memory

retrieval. Because the images are dynamic and adjustable in numerous

ways, the pulse simulator does provide an interesting perspective on

pulse training. It was recently demonstrated to PCOM academic

administrators with advanced degrees in educational technology and

given high marks for both design and potential usefulness. I penned

some thoughts about this tool for PCOM.

 

Briefly, the pulse simulator displays a dynamic graphic display of

pulse waves as well as an image of the pulse being palpated. The

images can be adjusted into 100's of graphic combinations, thus making

them far more useful than the static images contained in books like the

Web. The way I would envision the pulse simulator being used as a

teaching aid would be as a memory tool. For example, the teacher could

select the parameters of the bowstring or wiry pulse without revealing

the name of the pulse to the students. Then students can test their

accuracy at identifying the pulse based upon its characteristics rather

than its name. For example, bowstring is taut, narrow, with a distinct

edge. Bob Flaws believes this is one of the keys to pulse mastery:

memorizing the classical pulse images.

 

1. students feel a pulse

 

2. enter the basic characteristics of the pulse into the pulse

simulator

 

3. examine the pulse wave and graphic image to see if it correlates

with your felt sensation (the wave can actually be slowed to up to 1/16

speed which reveals very subtle characteristics of the pulse image).

 

4. attempt to label the pulse with a classical description

(drumskin/tympanic; hollow/leekstalk, etc.)

 

5. select the classical pulse from the menu and see how it compares to

the parameters entered.

 

Real life pulses often vary from classical pulses in that since they

represent the interaction of multiple imbalances, mixed pulse images

are more likely than pure ones. So the classical slippery pulse has no

wiriness in it. But in real life, patients often have pulses that are

wiry overlaid with slippery. The pulse simulator can graphically

display the differences in pulse wave between a wiry, slippery pulse

and pure slippery and pure wiry, plus introduce numerous other

variables. The images are meant to be representational, not

photographic. They are a map, not the terrain. Just as the words that

describe pulses do not replace the actual palpation of the pulse,

neither do these dynamic simulations. They are just one more way to

try and grasp the information.

 

Pulse teachers cannot use the simulator effectively until they are

calibrated to it themselves. One must be familiar with the images in

order to use them effectively as a teaching tool. In other words, one

must spend some time correlating ones current ways of storing pulse

images with that of the simulator. This type of simulation may lend

itself well to the pulse calibration necessary to do controlled

studies. A big flaw in current studies is that the practitioners are

allowed to make diagnoses for inclusion when it is well known that

actual agreement on key signs like pulses is rare amongst practitioners

who did not receive the same exact pulse training from a single teacher

and adhere to it strictly. This type of simulation may allow a degree

of calibration amongst those with different pulse teachers that was not

formerly possible.

 

 

 

Chinese Herbs

 

 

FAX:

 

 

 

[Guest guest]

On Aug 7, 2004, at 10:59 AM, wrote:

 

> it is well known that

> actual agreement on key signs like pulses is rare amongst practitioners

> who did not receive the same exact pulse training from a single teacher

> and adhere to it strictly.

 

Here in the states, that seems to be an accurate statement. However

when I was comparing my pulse reading with practitioners in a hospital

in Kunming, China, there was an astounding level of agreement.

 

--

 

Pain is inevitable, suffering is optional.

-Adlai Stevenson

[Guest guest]

>On Aug 7, 2004, at 10:59 AM, wrote:

>

>> it is well known that

>> actual agreement on key signs like pulses is rare amongst practitioners

>> who did not receive the same exact pulse training from a single teacher

>> and adhere to it strictly.

 

>At 12:37 PM -0700 8/7/04, Al Stone wrote:

>Here in the states, that seems to be an accurate statement. However

>when I was comparing my pulse reading with practitioners in a hospital

>in Kunming, China, there was an astounding level of agreement.

--

 

Al,

 

I'm glad to see this is not just my experience. While I was was in

China recently, I was fortunate to sit briefly with a " pulse master "

(according to his reputation), and in seeing many patients, my

recording of the overall qualities was 100% in agreement with his

patient records.

 

On the other hand, I've also sat with many other doctors who were

clearly uninterested in pulse diagnosis, and with whom I had a very

low agreement of the pulse qualities we felt.

 

I conclude from these experiences that well trained pulse takers can

usually agree when they identify the main qualities, even if they

come from very different training lineages. The standards for

identifying pulse qualities has been well established and consistent

since the Han dynasty, so there is really no reason for disagreement.

What practitioners may well not agree upon is the interpretation,

overall diagnosis and treatment.

 

Rory

 

 

--

 

 

 

[Guest guest]

, Al Stone <alstone@b...> wrote:

 

> Here in the states, that seems to be an accurate statement. However

> when I was comparing my pulse reading with practitioners in a hospital

> in Kunming, China, there was an astounding level of agreement.

>

> --

>

> Pain is inevitable, suffering is optional.

> -Adlai Stevenson

 

With all due respect, your statement implies that you are always in agreement

with the

assumedly expert chinese docs you mention and most of those around you in the

states

are inept and unable to match your skill in this area. That the issue is not

getting similar

training, but purely one of skill, a skill you imply most people lack (either

due to innate

incompetence or laziness or bad teachers, I assume). Did I get that right? I

have worked

at times with up to five doctors, all from chengdu, and none of them ever agee

about

anything behind each other's back, whatever they may say in public to each

other's faces.

Is it possible that that the praise you received from your teachers in China was

part of the

fee you paid to be there? I bet they are advised to tell visiting americans

whatever they

want to hear. I am not challenging your pulsetaking skills; I just doubt that

either you or

Rory are reporting anything of true significance here. There are just too many

unknown

variables at play.

 

[Guest guest]

At 3:47 AM +0000 8/8/04, wrote:

>With all due respect, your statement implies that you are always in

>agreement with the assumedly expert chinese docs you mention and

>most of those around you in the states are inept and unable to match

>your skill in this area. That the issue is not getting similar

>training, but purely one of skill, a skill you imply most people

>lack (either due to innate incompetence or laziness or bad teachers,

>I assume). Did I get that right? I have worked at times with up to

>five doctors, all from chengdu, and none of them ever agee about

>anything behind each other's back, whatever they may say in public

>to each other's faces. Is it possible that that the praise you

>received from your teachers in China was part of the fee you paid to

>be there? I bet they are advised to tell visiting americans

>whatever they want to hear. I am not challenging your pulsetaking

>skills; I just doubt that either you or Rory are reporting anything

>of true significance here. There are just too many unknown

>>variables at play.

--

 

 

 

Interesting. You engage in discussions on inter-rater reliability,

and when someone, in this case Al, brings up counter-examples to your

opinion from their personal experience, you try to denigrate the

value of that input. Contrary to your comment above, Al made no claim

as to the expertise of the doctors in Kunming, nor his own. Neither

did he make any special claims for his experiential observation, or

for his own skills. His observations have as much or as little value

as anyone's, including your own. Meanwhile, you counter his offering

with the laughable example from your own experience of people talking

behind each other's backs -- imagine the variables influencing that

situation -- as evidence of...what exactly?

 

In the event I mentioned, while sitting with a doctor seeing his

patient's in China, I wrote down my own notes including the overall

pulse qualities of a sequence of patients. I did make a claim as to

his expertise, based on his reputation amongst his colleagues as a

" pulse master " . I asked the translator to read the overall pulse

quality recorded in the patient chart by the doctor. There was 100%

agreement between my record of the overall pulse quality and his

written record. The sample was small, perhaps 20 to 30 patients, but

I don't see any variables undermining the level of agreement I

observed. No doubt we would not have agreed on much else, but on the

standard pulse qualities, we seemed to agree.

 

Perhaps an anecdote such as this has little significance in the broad

scheme of things, but it is surely of some interest when the

discussion turns to inter-rater reliability, at least to those not

totally bound by their own prejudices. This was an example where

there were no known common denominators between us, other than the

literature. The doctor in question was an older man who was very

highly regarded, not just for his pulse skill, but as a

scholar/teacher, and as a practitioner. Aside from clinic, I heard

him lecture on aspects of the jin gui yao lue, and he certainly lived

up to his reputation in that arena.

 

The only other person I have achieved that level of agreement was my

pulse teacher, Leon Hammer, who I studied with for several years, and

for whom I taught pulse diagnosis when he was satisfied with my

abilities.

 

If you are serious about wanting to look into these issues, why don't

you get your 5 doctors from Chengdu to take the pulses of a series of

subjects, and record their overall pulse qualities, perhaps just on

one side to reduce variables, and see what their rate of agreement

really is. Short of doing something like that, your conclusions would

seem to be based on rumors.

 

Rory

--

 

 

 

[Guest guest]

The other possibility is that Chinese patients have different pulses that are

more easily

read. Certainly after years of looking at 100 or so tongues a week in the

States, the

tongues in Beijing were completely different and almost across the board " more

normal " .

Or at least fit the textbook descriptions. And yes, it also seemed the pulses

fit the patterns

more clearly.

Note, that I'm not making a case for a racial difference but cultural

possibilities. Perhaps

the lifestyle and cultural better fits the categories of pulse qualities. A

better lifestyle, such

as the wonderful 2 hour lunch break, makes them healthier and less complicated.

Rory, do

you think a detailed Hammer system would be needed in China? I find most pulses

here

very complex which I believe reflects the pressures of our lives. And I will

debate this

point, yes I will!

 

doug

 

 

 

, Rory Kerr <rorykerr@o...> wrote:

> At 3:47 AM +0000 8/8/04, wrote:

> >With all due respect, your statement implies that you are always in

> >agreement with the assumedly expert chinese docs you mention and

> >most of those around you in the states are inept and unable to match

> >your skill in this area. That the issue is not getting similar

> >training, but purely one of skill, a skill you imply most people

> >lack (either due to innate incompetence or laziness or bad teachers,

> >I assume). Did I get that right? I have worked at times with up to

> >five doctors, all from chengdu, and none of them ever agee about

> >anything behind each other's back, whatever they may say in public

> >to each other's faces. Is it possible that that the praise you

> >received from your teachers in China was part of the fee you paid to

> >be there? I bet they are advised to tell visiting americans

> >whatever they want to hear. I am not challenging your pulsetaking

> >skills; I just doubt that either you or Rory are reporting anything

> >of true significance here. There are just too many unknown

> >>variables at play.

> --

[Guest guest]

, " " wrote:

> The other possibility is that Chinese patients have different pulses that are

more easily

> read.

And yes, it also seemed the pulses fit the patterns

> more clearly.

> Note, that I'm not making a case for a racial difference but cultural

possibilities. Perhaps

> the lifestyle and cultural better fits the categories of pulse qualities. A

better lifestyle,

such

> as the wonderful 2 hour lunch break, makes them healthier and less

complicated.

 

However the chinese actually have far worse mortality and morbidity statistics

than

American, so I doubt they are healthier across the board. When were you guys

there? With

the rise of the middle class and fast food and western lifestyles, I suspect

there will be

changes. But I would agree that the pulses of the paesantry would be

uncomplicated by

some of the artificial stresses of modern life, much of which exist solly in

one's own mind.

 

 

[Guest guest]

At 5:59 PM +0000 8/8/04, wrote:

> Rory, do you think a detailed Hammer system would be needed in China?

--

Doug,

 

The system that Hammer teaches originated in Shanghai, where it was

taught to John Shen, I guess in the 1920s, during his training with a

Dr King. Shen taught Hammer starting in the 1970s. How what Hammer

now teaches looks like what Shen was taught in the 1920s is a

different question, but the basis was certainly used in China,

(perhaps it still is, by others who studied with Shen's teacher, and

their students). No doubt in teaching Hammer, which was done in

clinic, Shen would have emphasized what he was seeing here in New

York, so the transmission would have reflected that. Also reflected

would have been the difficulties of transmitting information in

English, to a physician relatively untrained in Chinese medicine.

 

Personally I have found several of the more refined aspects of the

Hammer system present on patients in China, but have not had the

opportunity to explore the clinical relevance there to see how

helpful it might be. Of course, the Hammer system includes the

standard Chinese pulse as its basis, so that aspect is as useful as

the practitioner is able to make it.

 

 

>I find most pulses here very complex which I believe reflects the

>pressures of our lives. And I will debate this point, yes I will!

--

I'd say that life in China is pretty high pressure, but obviously of

a different sort than here, and with different ways of compensating

for the pressure. Its quite possible that the meanings of various

pulse phenomena may vary between cultures and races, and the

frequency with which they are experienced.

 

Rory

--

 

 

 

[Guest guest]

At 7:06 PM +0000 8/8/04, wrote:

>When were you guys there?

--

I was in Beijing in 1992, and Nanchang in 2002. There was a radical

difference in the level of consumerism.

 

I think its very difficult to draw detailed conclusions based on

mortality and morbidity stats. China and the USA struggle with some

very different public health issues, not least population density and

a large percentage of people in China living in relentless poverty.

 

Rory

--

 

 

 

[Guest guest]

I was in Shanghai in 1995 and Beijing in 2002. I am not neccesarily making the

case that

the Chinese are healthier, just that their tongues and pulses more conform to

TCM

standards. The other thing to consider is how much better food tastes in China.

I don't

mean the cuisine or cooking skill but the actual quality of the raw materials.

In Shanghai,

in 95, everybody, including the doctors, were riding bikes long distances

everyday. In

2002, bikes were less common and 10 billion cabs were on the street.

 

doug

 

 

wrote:

> >When were you guys there?

> --

> I was in Beijing in 1992, and Nanchang in 2002. There was a radical

> difference in the level of consumerism.

>

> I think its very difficult to draw detailed conclusions based on

> mortality and morbidity stats. China and the USA struggle with some

> very different public health issues, not least population density and

> a large percentage of people in China living in relentless poverty.

>

> Rory

> --

>

>

>

[Guest guest]

In reply to a number of comments about pulse taking issues:

 

The Pulse Simulator that Curt Kruse and I have developed is very consistent with

the way that classical pulses are described in the literature. Basic parameters

such as rate, pulse rhythm regularity, strength, depth (floating/sinking),

width, pulse profile features (pressure pulse duration or " length " , rate of

onset or " tidal-ness " , choppiness, slipperiness/smoothness), and elasticity are

all qualities that are described in the traditional literature. We've added a

few to make things logically consistent: depth spread and edge quality

(fuzzy/distinct). In talking with people who have chosen to specialize in

pulses, including several who have studied with Leon Hammer, I'm convinced that

it is a mistake to have new students begin by memorizing the 28 classical pulse

types and their properties - this may be fine for advanced students, but for new

students it leads to the bad habit of attempting to arbitrarily force fit a

complicated pulse into one of the 28 classical types. For the past 15 years,

I've taught new students to systematically focus on describing each basic

parameter of the pulse, and then once their written description is complete,

only then attempting to see if certain parameters correspond with specific

classical pulse types by searching through the textbook.

 

As an example of how this works, consider a pulse that has the following basic

parameters:

Rate=rapid

Rhythm=normal

Strength=strong

Width=wide

Boundary=distinct

Time profile characteristics:

Length=normal

Choppiness=choppy

Slipperiness=slippery

Tidalness(onset)=slightly tidal (rapid onset)

Elasticity=taut

 

If one searches the definitions of the 28 classical types, there are found to be

aspects of several classical pulses types. A classical slippery pulse is strong,

wide, fuzzy-edged, and has a slippery time profile (like a pearl gliding beneath

one's fingers); here there is a partial match, except that the boundary is

distinct. A classical bowstring pulse is strong, narrow, distinct-edged, and

taut; here there is a partial match except that the width is narrow and the

elasticity is taut. A classical tidal pulse is very strong, wide, and long

(pulse duration), and has a rapid onset (Tidal-ness = slightly tidal); here the

strong and somewhat rapid-onset characteristics suggest a hint of the classical

tidal quality. In addition, the choppiness here manifests not as a " knife

scraping over bamboo " , since the slippery profile will smooth out the pulse

shape in time, but rather the turbulence in blood flow will manifest as a slight

variation in the shape of each subsequent pressure pulse in time. This is the

type of pulse that might be described as " slippery " , " slippery-bowstring " , or

even as " slippery-bowstring-choppy-tidal " , and might be felt in a case of

Phlegm/Dampness + Qi and Blood Stasis + low-grade Blood Heat. (This is

reminiscent of the story of the three blind men describing an elephant,

depending which part of its body they are holding; the one holding the trunk

describes the elephant as being like a snake, the one holding the tail, as being

like a rope, and the one holding one of the legs, as being like a tree trunk.)

All of the preceding classical terms are only partially accurate because none

completely describes all the details of this pulse. The only way to accurately

encompass all of the relevant details is to describe each parameter separately.

Another way to look at this is to consider that with 12 independent pulse

parameters, each with from 4 to 10 possible values, there are a total of

1,290,777,600 unique pulses that can be described. Hopefully, one can see the

absurdity of attempting to force fit a pulse description into one or even a

combination of the 28 classical pulse types, many of these already a combination

of basic parameters. Rather, the 28 classical pulses should be considered as

special examples that clearly point to specific patterns of disharmony, rather

than as primary descriptive terms, as they are used by the majority of TCM

practitioners.

 

The main problem I've observed over 15 years of teaching is that students and

practitioners do not attempt to systematically describe pulses in terms of their

basic parameters, but instead often directly attempt to match what they feel

with one of the 28 classical pulse types. Leon Hammer's approach is a step in

the right direction, in that he insists on breaking down pulses into a much

greater range of characteristics than are possible among the classical types,

and also notes that it is often important to distinguish pulse qualities that

may differ with level - superficial, middle, and deep. For example, one can have

a narrow, distinct-edged, slightly taut pulse at the superficial level, yet have

a wide, very taut pulse with a slippery time-profile at the deep level,

something one might feel in cases of Qi Stagnation with Congealed Phlegm

(tumors). However, many people find it difficult to interpret the

two-dimensional diagrams in Hammer's books. Other authors have also tried to use

various two-dimensional graphical coding systems to represent pulses, but it is

physically impossible to represent a 4-dimensional phenomena (length along

artery, width, depth, and time) using only two dimensions. Video simulations

that display the arterial cross-sections and the pulse time profile solve this

problem.

 

Our students who play around with the Pulse Simulator prior to attending

seminars invariably learn pulses much faster. Recently I had the experience of

teaching several physicians whose only exposure to TCM pulse taking was the

Pulse Simulator and the accompanying text. After 6 days of training, their

descriptions of individual pulse parameters matched my own about 70-80%.

Physicians already have a lot of experience feeling pulses, and an accurate and

systematic way of describing the pulses will allow them to attach labels to

sensations that they recognize from past experience. For others with little

health care experience, developing sensitivity in the fingertips to fell

anything at all may be a challenge, and these students should be encouraged to

simply keep practicing and to describe what they think they feel. To force these

students to jump to conclusions about which of the 28 pulse types might be

relevant or descriptive simply short-circuits the learning process, which, I

believe, is why many people do not have confidence in pulse-taking.

 

We've posted a few examples of screen shots of various simple and complex pulse

types displayed on the Pulse Simulator at:

 

http://www.rmhiherbal.org/tchs-cd/pu-01.html

 

(Keep in mind that these are snapshots of moving images.)

 

 

---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]

On Aug 7, 2004, at 8:47 PM, wrote:

 

> , Al Stone <alstone@b...>

> wrote:

>

>> Here in the states, that seems to be an accurate statement. However

>> when I was comparing my pulse reading with practitioners in a hospital

>> in Kunming, China, there was an astounding level of agreement.

>>

>> --

>>

>> Pain is inevitable, suffering is optional.

>> -Adlai Stevenson

>

> With all due respect, your statement implies that you are always in

> agreement with the

> assumedly expert chinese docs you mention and most of those around you

> in the states

> are inept and unable to match your skill in this area. That the issue

> is not getting similar

> training, but purely one of skill, a skill you imply most people lack

> (either due to innate

> incompetence or laziness or bad teachers, I assume). Did I get that

> right?

 

Nope, I think its more about the training. There is a finite number of

qualities that TCM training focuses on and when the number of variables

are less, the number of agreements is greater. I found that we all

generally agreed on deep/superficial, fast/slow, strong/weak,

thin/wide, and wave characteristics such as slippery and wiry. I don't

recall running into a Choppy in China, can't really comment on that.

 

> I have worked

> at times with up to five doctors, all from chengdu, and none of them

> ever agee about

> anything behind each other's back, whatever they may say in public to

> each other's faces.

> Is it possible that that the praise you received from your teachers in

> China was part of the

> fee you paid to be there? I bet they are advised to tell visiting

> americans whatever they

> want to hear. I am not challenging your pulsetaking skills; I just

> doubt that either you or

> Rory are reporting anything of true significance here.

 

My theory is that there are just too many pulse teachers here directing

students in one direction, then another, then a third, all of which

result in a lowered inter-rater reliability. My experience in China was

such that I was convinced that TCM training was consistent between what

I learned and what they were doing in Kunming.

 

I don't think that anybody was trying to make me feel good about my

pulse taking abilities for monetary gain.

 

--

 

Pain is inevitable, suffering is optional.

-Adlai Stevenson

[Guest guest]

Rorger Wicke wrote:

>The main problem I've observed over 15 years of teaching is that students and

>practitioners do not attempt to systematically describe pulses in terms of

>their basic parameters, but instead often directly attempt to match what they

>feel with one of the 28 classical pulse types.

--

 

Roger,

 

I completely agree with you, and it is the approach I use both in teaching

students and in professional seminars. Students seem to find learning the 28

qualities and beyond much easier having started with this as the basis. It also

give a method for analyzing pulses they are confused by: rather than try to fit

the pulse to a standard definition, simply analize the parameters of sensation

under the fingers and write them down. Each parameter has some fairly likely

diagnostic meaning, so even though the practitioner finds it hard to name the

exact quality, they can still use the pulse findings in their diagnosis.

 

Rory