Guest guest Posted June 24, 2006 Report Share Posted June 24, 2006 CHA Listees I thought some (perhaps at least a few) would be interested in a little math I have had to do in the development (still in process) of a realistic computer based simulation of writing an individually tailored prescription for a complex presentation. Here are the parameters: 1. A case that could be reframed under the rubric of four chinese disease categories, either because multiple categories might apply to a single chief complaint and/or the patient has more than one major complaint (consider chronic fatigue syndrome, for example, which might present as fatigue, lymphadenopathy, frequent colds and flus, fever, insomnia, joint pain, etc.) 2. For each of the four disease categories, provide three formula options. Again, the same disease/pattern combination might be treated with any number of formulas and/or more than one pattern might be relevant to a given disease (for example, phlegm and qi vacuity contributing to frequent colds and flus), all depending on the personal biases or schools of thought one might adhere to. 3. So that one case might result in 12 possible base formulas to choose from in this scenario. Now lets say you could choose 1 base formula or combine 2 (for example, bu zhong yi qi wan and er chen wan), if one considers all possible combinations in this scenario, there are 102 possible options. 4. Now let's allow that one might choose between six possible standard modifications for each formula or pair by selecting just two pairs (or groups) of herbs to add to the base prescription (to build on my example, to the bu zhong/er chen combination, one adds xuan shen and bei mu for lymphadenopathy and jin yin hua and lian qiao for the presence of toxic heat). 6 possible options combined in all possible pairs yields 15 unique modifications for formula or formula combination. 5. The 102 possible base prescriptions (12 single formulas or any 2 combined into all possible pairs) thus leads to 1530 possible unique formulas as outcomes (15 X 102). After this one would then need to make appropriate deletions for the final rx (which could exponentially increase the unique formula possibilities depending on the number of herbs in each formula and how many one chose to delete). Now, granted, many of the final formulas will be similar or almost identical (this is something that often occurred in assigning cases in my upper level herbology courses, where one group one chose two base formulas and modified them, while another would choose two different ones and modify them, the net result sometime being very similar formulas—consider adding phlegm herbs to si jun zi tang or qi supplements to er chen wan or just starting with liu jun zi wan as a simple example of this). Nevertheless, though the differences may be subtle (perhaps just a few herbs at times), the scenario I describe would still result in over 1500 different formulas (I am sure of this because I have storyboarded the scenario in powerpoint and it took 1600 slides to capture all the permutations. And that is by using a circumscribed template that only allows the combination of two formulas and two pairs of modifications at most. In real, the options are virtually infinite (if one allows for all 5.767 herbs in the zhong yao da ci dian) So what does all this mean? Well first it means we need to cut our students some slack in our expectations about what they can possibly accomplish off the top of their heads in clinic. But second and more important, it provides for the development of a tool to walk students through the process and allow them to go back over and over again to see how a given choice leads one down multiple pathways, all of which are conceivably correct. As soon as I have this completed (as you might guess, the process of creating a working simulation is extremely laborious), I plan to offer an online CEU class that uses this type of simulation as the first step in learning how to do complex formulation from scratch. Considerable research has shown that using a structured organizer such as I have outlined above is far more effective in teaching various skills than either merely studying texts or attempting to apply the entire process in a structureless (i.e., constructivist) fashion. Educational theorists call this process scaffolding as it provides support in the learning process which can be removed after a certain amount of foundation has been established. BTW, in case anyone wondered what happened to my herb game idea I announced a while back. It has morphed into this project and has taken far longer than I anticipated. I was able to cobble together a simplistic version of this idea to submit as a project for a grad class, but it was beneath of all of your talents to bother passing it along for professional scrutiny. Chinese Herbs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 sounds good, Todd. Would there be a cutoff of the number of herbs that could be in the final formula. This may limit the possibilities yet make the student to go back to priortize the complaints and weigh the value of each of the formulas or parts of the formula that make up the final. doug , < wrote: > > CHA Listees > > I thought some (perhaps at least a few) would be interested in a > little math I have had to do in the development (still in process) of > a realistic computer based simulation of writing an individually > tailored prescription for a complex presentation. Here are the > parameters: > > 1. A case that could be reframed under the rubric of four chinese > disease categories, either because multiple categories might apply to > a single chief complaint and/or the patient has more than one major > complaint (consider chronic fatigue syndrome, for example, which > might present as fatigue, lymphadenopathy, frequent colds and flus, > fever, insomnia, joint pain, etc.) > > 2. For each of the four disease categories, provide three formula > options. Again, the same disease/pattern combination might be > treated with any number of formulas and/or more than one pattern > might be relevant to a given disease (for example, phlegm and qi > vacuity contributing to frequent colds and flus), all depending on > the personal biases or schools of thought one might adhere to. > > 3. So that one case might result in 12 possible base formulas to > choose from in this scenario. Now lets say you could choose 1 base > formula or combine 2 (for example, bu zhong yi qi wan and er chen > wan), if one considers all possible combinations in this scenario, > there are 102 possible options. > > 4. Now let's allow that one might choose between six possible > standard modifications for each formula or pair by selecting just two > pairs (or groups) of herbs to add to the base prescription (to build > on my example, to the bu zhong/er chen combination, one adds xuan > shen and bei mu for lymphadenopathy and jin yin hua and lian qiao for > the presence of toxic heat). 6 possible options combined in all > possible pairs yields 15 unique modifications for formula or formula > combination. > > 5. The 102 possible base prescriptions (12 single formulas or any 2 > combined into all possible pairs) thus leads to 1530 possible unique > formulas as outcomes (15 X 102). After this one would then need to > make appropriate deletions for the final rx (which could > exponentially increase the unique formula possibilities depending on > the number of herbs in each formula and how many one chose to delete). > > Now, granted, many of the final formulas will be similar or almost > identical (this is something that often occurred in assigning cases > in my upper level herbology courses, where one group one chose two > base formulas and modified them, while another would choose two > different ones and modify them, the net result sometime being very > similar formulas—consider adding phlegm herbs to si jun zi tang or qi > supplements to er chen wan or just starting with liu jun zi wan as a > simple example of this). Nevertheless, though the differences may be > subtle (perhaps just a few herbs at times), the scenario I describe > would still result in over 1500 different formulas (I am sure of this > because I have storyboarded the scenario in powerpoint and it took > 1600 slides to capture all the permutations. And that is by using a > circumscribed template that only allows the combination of two > formulas and two pairs of modifications at most. In real, the > options are virtually infinite (if one allows for all 5.767 herbs in > the zhong yao da ci dian) > > So what does all this mean? Well first it means we need to cut our > students some slack in our expectations about what they can possibly > accomplish off the top of their heads in clinic. But second and more > important, it provides for the development of a tool to walk students > through the process and allow them to go back over and over again to > see how a given choice leads one down multiple pathways, all of which > are conceivably correct. As soon as I have this completed (as you > might guess, the process of creating a working simulation is > extremely laborious), I plan to offer an online CEU class that uses > this type of simulation as the first step in learning how to do > complex formulation from scratch. Considerable research has shown > that using a structured organizer such as I have outlined above is > far more effective in teaching various skills than either merely > studying texts or attempting to apply the entire process in a > structureless (i.e., constructivist) fashion. Educational theorists > call this process scaffolding as it provides support in the learning > process which can be removed after a certain amount of foundation has > been established. > > BTW, in case anyone wondered what happened to my herb game idea I > announced a while back. It has morphed into this project and has > taken far longer than I anticipated. I was able to cobble together a > simplistic version of this idea to submit as a project for a grad > class, but it was beneath of all of your talents to bother passing it > along for professional scrutiny. > > > > Chinese Herbs > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 Hi Doug I encouraged my students to write formulas in the 12-15 ingredient ranges for complex cases. Less than that often did not cover the necessary tx principles and more ended up in sloppy formulation. In my experience, effective formulas can be larger or smaller than this range, but it is a more sophisticated skill to be able to be able to write such formulas. My class is geared for students, recent grads, or those who never got adequate herbal training. You make a good point, though and one I hadn't really thought of yet. If more than one of the base formulas for a case contains 8 or more ingredients, that would make it much less likely that those two formulas would be combined in the first place. OTOH, many of the larger formulas that might be options for a given disease/pattern combination have overlapping ingredients. For example, Ba zhen tang and gui pi wan. But it might be asked why you would choose to combine these two in the first place. If you chose gui pi and needed to add the elements of ba zhen, you would actually only need to add si wu tang. But si wu tang would probably not be a primary option in such a case and I think it would not be uncommon for a novice to consider both of these formulas (gui pi and ba zhen) in a case of qi and blood vacuity and only upon closer inspection would one realize the overlap. But the starting place could still certainly be the desire to combine these two to achieve the benefits of both. It might be helpful to consider a given case and look at how one might set up the basic options in way that would allow or prohibit large numbers of possible combinations based upon the parameters of a 12-15 herb final rx (keeping in mind that deletions would be typical). Also, he purpose of the exercise is not really to limit the choices, but rather demonstrate: 1. how many different paths to solution there can be in a given case 2. a style of practice that uses a limited number of selected " building-block " formulas in numerous combinations as the primary approach to treating complex cases As such, my choices have been made to serve this goal. Students can choose only one base formula and modify it, but that approach still yields 108 possible options under this format. As an aside, this might be why the typical approach to education and practice in china seems to center around selection and modification of a single formula. For many beginners, anything else verges on insanity. The beauty of a case scenario like this is that a single case can be tackled in the simulation multiple times at many levels of difficulty depending upon whether one uses 1 or 2 base rx and which ones are selected. I will continue to use chronic fatigue as my example as I do not intend to use this as my actual simulation case. Dx = Qi vacuity, phlegm-heat accumulation, damp-heat, heart blood vacuity, blood stasis, liver depression (keep in mind I do not to the idea that one must treat all of these to unravel the case; I base this opinion on having observed numerous cases that exhibited long term resolution by only addressing several of the patterns present) Dz 1 - fatigue Rx 1 - bu zhong yi qi tang Rx 2 - ba zhen tang Rx 3 - xiao yao san Dz 2 - cough Rx 1 - qing jin hua tan tang Rx 2 - liu jun zi tang Rx 3 - bu fei tang Dz 3 - insomnia Rx 1- suan zao ren wan Rx 2 - ding zhi wan Rx 3 - wen dan tang Dz 4 - musculoskeletal pain Rx 1 - huo luo xiao ling dan Rx 2 - er miao san Rx 3 - ?? (couldn't think of another right now and and had to leave most of my books in AZ due to the expense of moving them) Now, admittedly, as I wrote this, it became clear that some combinations were less likely than others and certain questions were raised in my mind. For example, would anyone really start with a combination of er miao san and huo luo xiao ling dan? Perhaps, if one's approach was to address branch symptoms first and always relieve pain before doing anything else. Or would a person ever select wen dan tang and suan zao ren wan as primary rx? Again, perhaps if one was influenced by the idea that sleep disorder may be a major factor in CFS. On Jun 25, 2006, at 3:37 AM, wrote: > sounds good, Todd. Would there be a cutoff of the number of herbs > that could be in the > final formula. This may limit the possibilities yet make the > student to go back to priortize > the complaints and weigh the value of each of the formulas or parts > of the formula that > make up the final. > doug Chinese Herbs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 Actually I probably use Wen Dan Tang as a base with a look towards Qing qi hua tan Wan. So here we have an issue of taste as I wouldn't put any of the fatigue formulas in there until the phlegm was cut down and then I would hope that they would then get better as well. Blood movers may play in the initial formula and given that one could even make an initial case for Yue Ju Wan solely! But of course I don't have all the facts... So what we see here doesn't have a zang-fu or qi dynamic that can tie together several formulas. But that's a whole other level of prioritizing and complexity. Anyway, it sounds like this program mimics how I and others think about constructing formulas. Very good. doug , < wrote: > > Hi Doug > > I encouraged my students to write formulas in the 12-15 ingredient > ranges for complex cases. Less than that often did not cover the > necessary tx principles and more ended up in sloppy formulation. In > my experience, effective formulas can be larger or smaller than this > range, but it is a more sophisticated skill to be able to be able to > write such formulas. My class is geared for students, recent grads, > or those who never got adequate herbal training. > > You make a good point, though and one I hadn't really thought of yet. > If more than one of the base formulas for a case contains 8 or more > ingredients, that would make it much less likely that those two > formulas would be combined in the first place. OTOH, many of the > larger formulas that might be options for a given disease/pattern > combination have overlapping ingredients. For example, Ba zhen tang > and gui pi wan. But it might be asked why you would choose to combine > these two in the first place. If you chose gui pi and needed to add > the elements of ba zhen, you would actually only need to add si wu > tang. But si wu tang would probably not be a primary option in such a > case and I think it would not be uncommon for a novice to consider > both of these formulas (gui pi and ba zhen) in a case of qi and blood > vacuity and only upon closer inspection would one realize the > overlap. But the starting place could still certainly be the desire > to combine these two to achieve the benefits of both. > > It might be helpful to consider a given case and look at how one > might set up the basic options in way that would allow or prohibit > large numbers of possible combinations based upon the parameters of a > 12-15 herb final rx (keeping in mind that deletions would be > typical). Also, he purpose of the exercise is not really to limit the > choices, but rather demonstrate: > > 1. how many different paths to solution there can be in a given case > > 2. a style of practice that uses a limited number of selected > " building-block " formulas in numerous combinations as the primary > approach to treating complex cases > > As such, my choices have been made to serve this goal. Students can > choose only one base formula and modify it, but that approach still > yields 108 possible options under this format. As an aside, this > might be why the typical approach to education and practice in china > seems to center around selection and modification of a single > formula. For many beginners, anything else verges on insanity. The > beauty of a case scenario like this is that a single case can be > tackled in the simulation multiple times at many levels of difficulty > depending upon whether one uses 1 or 2 base rx and which ones are > selected. > > I will continue to use chronic fatigue as my example as I do not > intend to use this as my actual simulation case. > > Dx = Qi vacuity, phlegm-heat accumulation, damp-heat, heart blood > vacuity, blood stasis, liver depression (keep in mind I do not > to the idea that one must treat all of these to unravel the > case; I base this opinion on having observed numerous cases that > exhibited long term resolution by only addressing several of the > patterns present) > > Dz 1 - fatigue > Rx 1 - bu zhong yi qi tang > Rx 2 - ba zhen tang > Rx 3 - xiao yao san > > Dz 2 - cough > Rx 1 - qing jin hua tan tang > Rx 2 - liu jun zi tang > Rx 3 - bu fei tang > > Dz 3 - insomnia > Rx 1- suan zao ren wan > Rx 2 - ding zhi wan > Rx 3 - wen dan tang > > Dz 4 - musculoskeletal pain > Rx 1 - huo luo xiao ling dan > Rx 2 - er miao san > Rx 3 - ?? (couldn't think of another right now and and had to leave > most of my books in AZ due to the expense of moving them) > > Now, admittedly, as I wrote this, it became clear that some > combinations were less likely than others and certain questions were > raised in my mind. For example, would anyone really start with a > combination of er miao san and huo luo xiao ling dan? Perhaps, if > one's approach was to address branch symptoms first and always > relieve pain before doing anything else. Or would a person ever > select wen dan tang and suan zao ren wan as primary rx? Again, > perhaps if one was influenced by the idea that sleep disorder may be > a major factor in CFS. > > > > On Jun 25, 2006, at 3:37 AM, wrote: > > > sounds good, Todd. Would there be a cutoff of the number of herbs > > that could be in the > > final formula. This may limit the possibilities yet make the > > student to go back to priortize > > the complaints and weigh the value of each of the formulas or parts > > of the formula that > > make up the final. > > doug > > > > Chinese Herbs > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 Doug Good call on yue ju wan as an option. I was kind of just winging it. As for the issue of tonics at first, I am with you, but others might disagree. In any event, how you modified the base and dosed the herbs would be key. On Jun 25, 2006, at 5:46 PM, wrote: > Actually I probably use Wen Dan Tang as a base with a look towards > Qing qi hua tan Wan. > So here we have an issue of taste as I wouldn't put any of the > fatigue formulas in there > until the phlegm was cut down and then I would hope that they would > then get better as > well. Blood movers may play in the initial formula and given that > one could even make an > initial case for Yue Ju Wan solely! But of course I don't have all > the facts... > So what we see here doesn't have a zang-fu or qi dynamic that can > tie together several > formulas. But that's a whole other level of prioritizing and > complexity. > > Anyway, it sounds like this program mimics how I and others think > about constructing > formulas. Very good. > doug > > , < > wrote: > > > > Hi Doug > > > > I encouraged my students to write formulas in the 12-15 ingredient > > ranges for complex cases. Less than that often did not cover the > > necessary tx principles and more ended up in sloppy formulation. In > > my experience, effective formulas can be larger or smaller than this > > range, but it is a more sophisticated skill to be able to be able to > > write such formulas. My class is geared for students, recent grads, > > or those who never got adequate herbal training. > > > > You make a good point, though and one I hadn't really thought of > yet. > > If more than one of the base formulas for a case contains 8 or more > > ingredients, that would make it much less likely that those two > > formulas would be combined in the first place. OTOH, many of the > > larger formulas that might be options for a given disease/pattern > > combination have overlapping ingredients. For example, Ba zhen tang > > and gui pi wan. But it might be asked why you would choose to > combine > > these two in the first place. If you chose gui pi and needed to add > > the elements of ba zhen, you would actually only need to add si wu > > tang. But si wu tang would probably not be a primary option in > such a > > case and I think it would not be uncommon for a novice to consider > > both of these formulas (gui pi and ba zhen) in a case of qi and > blood > > vacuity and only upon closer inspection would one realize the > > overlap. But the starting place could still certainly be the desire > > to combine these two to achieve the benefits of both. > > > > It might be helpful to consider a given case and look at how one > > might set up the basic options in way that would allow or prohibit > > large numbers of possible combinations based upon the parameters > of a > > 12-15 herb final rx (keeping in mind that deletions would be > > typical). Also, he purpose of the exercise is not really to limit > the > > choices, but rather demonstrate: > > > > 1. how many different paths to solution there can be in a given case > > > > 2. a style of practice that uses a limited number of selected > > " building-block " formulas in numerous combinations as the primary > > approach to treating complex cases > > > > As such, my choices have been made to serve this goal. Students can > > choose only one base formula and modify it, but that approach still > > yields 108 possible options under this format. As an aside, this > > might be why the typical approach to education and practice in china > > seems to center around selection and modification of a single > > formula. For many beginners, anything else verges on insanity. The > > beauty of a case scenario like this is that a single case can be > > tackled in the simulation multiple times at many levels of > difficulty > > depending upon whether one uses 1 or 2 base rx and which ones are > > selected. > > > > I will continue to use chronic fatigue as my example as I do not > > intend to use this as my actual simulation case. > > > > Dx = Qi vacuity, phlegm-heat accumulation, damp-heat, heart blood > > vacuity, blood stasis, liver depression (keep in mind I do not > > to the idea that one must treat all of these to unravel > the > > case; I base this opinion on having observed numerous cases that > > exhibited long term resolution by only addressing several of the > > patterns present) > > > > Dz 1 - fatigue > > Rx 1 - bu zhong yi qi tang > > Rx 2 - ba zhen tang > > Rx 3 - xiao yao san > > > > Dz 2 - cough > > Rx 1 - qing jin hua tan tang > > Rx 2 - liu jun zi tang > > Rx 3 - bu fei tang > > > > Dz 3 - insomnia > > Rx 1- suan zao ren wan > > Rx 2 - ding zhi wan > > Rx 3 - wen dan tang > > > > Dz 4 - musculoskeletal pain > > Rx 1 - huo luo xiao ling dan > > Rx 2 - er miao san > > Rx 3 - ?? (couldn't think of another right now and and had to leave > > most of my books in AZ due to the expense of moving them) > > > > Now, admittedly, as I wrote this, it became clear that some > > combinations were less likely than others and certain questions were > > raised in my mind. For example, would anyone really start with a > > combination of er miao san and huo luo xiao ling dan? Perhaps, if > > one's approach was to address branch symptoms first and always > > relieve pain before doing anything else. Or would a person ever > > select wen dan tang and suan zao ren wan as primary rx? Again, > > perhaps if one was influenced by the idea that sleep disorder may be > > a major factor in CFS. > > > > > > > > > On Jun 25, 2006, at 3:37 AM, wrote: > > > > > sounds good, Todd. Would there be a cutoff of the number of herbs > > > that could be in the > > > final formula. This may limit the possibilities yet make the > > > student to go back to priortize > > > the complaints and weigh the value of each of the formulas or > parts > > > of the formula that > > > make up the final. > > > doug > > > > > > > > Chinese Herbs > > > > > > > Chinese Herbs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 Doug, Perhaps. In which case, perhaps there should be an option to select a formula and not choose any modifications at all. However, in most of the choices, I think that would be a bad option. On Jun 25, 2006, at 5:46 PM, wrote: > one could even make an > initial case for Yue Ju Wan solely! Chinese Herbs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 25, 2006 Report Share Posted June 25, 2006 Working with formulas, usually there is one that you go with and then use elements of the others to complement. I'm wondering for purposes of your program if rather than combining several formulas, use the base one and then use parts of the others. I don't know how the program will be structured so this may be moot (mute?). 2 more things that I'll bring up for the general CHA listeners. The first of the famous formula written (Jiao Shu-de?) based on Liu Wei Di Huang yet had none of it's ingredients. When questioned he replied: but it is the spirit of Liu Wei! This happens often actually. And then, say I have a formula to write of powdered or raw herbs. Then, for example, I would take Qing Qi Hua Tan Wan and modify it including taking out 2 or three of the herbs. However if I had to give an unmodified patent pill then I might give Yue Ju Wan because the " spirit " of the symptoms would best conform with no offending herbs within it. So the practicality of the situation might lead to different base formulas. doug , < wrote: > > Doug > > Good call on yue ju wan as an option. I was kind of just winging > it. As for the issue of tonics at first, I am with you, but others > might disagree. In any event, how you modified the base and dosed > the herbs would be key. > > > On Jun 25, 2006, at 5:46 PM, wrote: > > > Actually I probably use Wen Dan Tang as a base with a look towards > > Qing qi hua tan Wan. > > So here we have an issue of taste as I wouldn't put any of the > > fatigue formulas in there > > until the phlegm was cut down and then I would hope that they would > > then get better as > > well. Blood movers may play in the initial formula and given that > > one could even make an > > initial case for Yue Ju Wan solely! But of course I don't have all > > the facts... > > So what we see here doesn't have a zang-fu or qi dynamic that can > > tie together several > > formulas. But that's a whole other level of prioritizing and > > complexity. > > > > Anyway, it sounds like this program mimics how I and others think > > about constructing > > formulas. Very good. > > doug > > Quote Link to comment Share on other sites More sharing options...
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