Outcome Measurements,

February 14, 2008

Dear Trevor,

I appreciate your insights about dermatological treatments -- I have always

thought that one of the greatest things overlooked in our training is how

long it takes to effect a change. Then there is the problem if our treatment

protocol takes several months to yield apparent results was it the

treatments, other changes and a big one that I think is a factor is seasonal

change.

So many times, I noticed that treatments I would give for some conditions

seem to just maintain a person and then as soon as the sun comes out,

everything gets better. Then I have found that the next season when problems

are likely to occur, they don't or they are much less and that's when I get

to see that the work we did counted.

Its a problem for me because a lot of my influence as been from Dr. Miriam

Lee and she always opted for fast results -- a week, two weeks, -- I'm

impatient that way as well and I suspect it could be a problem in me.

I share with you the concern and need for some objective outcome

measurements. I have the same general bias against kinesiology but then

along comes something like " Omari's ring " which sounds to TCM or whatever

and people flock to it like lemmings, abandoning the rigors of TCM analysis

-- only to find that good results are attained by the " Omarians " .

Then what do we do with the many studies that claim that " sham' acupuncture

is as effective as 'non-sham' acupuncture -- at least they both prove the

value of acupuncture. As I understand it, it was these kinds of paradoxes

that caused Felix Mann to renounce all acupuncture theory at one point in

his career.

Again, I suspect it brings us back to my thesis that principles and theories

are guidelines and points of departure -- not to be construed as cut in

stone absolutes.

Michael Tierra

_____

On Behalf Of Trevor Erikson

Thursday, February 14, 2008 10:58 AM

Re: Outcome Measurements

Yes outcome measurements are extremely important to me as well. This

is why I chose to focus so much on the treatment of skin disorders. I

can use modern technology,ie. a camera, to measure the progress of

someones healing from start to finish. So if the patient or

practitioner are ever in doubt about the work being done, the picture

can be brought out to remind us of the original state. Progress cannot

be argued. The changes are very objective. Either the patient is

better or not.

I have seen people using psycho-spiritual/ energy healing methods to

heal objective problems like eczema. Try for many months, while being

put through various hypnotic trances and given remedies that were

based on the practitioners " intuition " , but there would be almost no

change in the skin. The practitioner would then say, " Oh, it is because

you still have some hatred left over from some past life " , or

something like this. I cannot even begin to talk about the amount of

money some of these healers charge for their services!

Then the same patient tries CM for a few months, using a remedy based

on the proper differentation of syndromes as deemed appropriate to

dermatology. A remedy based on patterns and science, rather than

intuition. Within a few weeks OBJECTIVE changes are noticed, the

patient gains confidence in the treatment and keeps going. Within a

few months, their eczema is almost completely gone, with no new flare ups.

The results can be measured. I hate nothing more than wasting my or a

patients time. I want to see changes that are obvious so that

everybody feels happy at the end of the day.

Trevor

@ <%40>

, " Al Stone " <al wrote:

>

> On Thu, Feb 14, 2008 at 10:10 AM, alon marcus <alonmarcus wrote:

>

> > I for one, however, believe a strong western based

> > scientific critical lens is a must in order to assess one's clinical

> > outcomes in a more meaningful way.

> Me too.

>

> This is the key reason that the psycho-spiritual applications have lost

> their luster in my mind. No measurable outcomes. If however one

really does

> want to go in that direction and starts asking themselves what a

measurable

> outcome for a spiritual intervention looks like, you may notice that

> eventually you are testing for clinical depression.

>

> --

> , DAOM

> Pain is inevitable, suffering is optional.

>

February 14, 2008

Hi Michael,

You are right about the lack of training in terms of knowing the

proper length of treatment. I have always been frustrated with this

lack of information in our TCM textbooks.

When I studied dermatology with Mazin in London, his style of teaching

was via pictures he took of his patients over the last couple decades.

The whole training was based on hundreds of these photos. So not only

did I gain insight into the DX from both a western and CM prospective,

I also got to see how to approach the disease when writing an Rx, and

most importantly got to learn how long to wait for change. He showed

us both the initial visit and then the end result.

For example I know now that when treating psoriasis with internal

herbs only, change will not be significant until at least the 5-7 week

mark. This is a long time to wait for both the practitioner and

patient. But having this knowledge of how long to wait can be very

useful clinically, allowing every one to relax and trust in the process.

Then there is knowing now long till the condition has completely

resolved. It is good to communicate this to the patient. Acne-say

12-16 weeks. Psoriasis- up to 6 months or longer, depending on the

severity.

My colleague Lorn Brown has a logo for his continuing education

classes (Pro-d) that is- knowledge, confidence, success. I feel that

when people lack proper training in certain areas, they will not be

able to effect the proper change and thus both the patient and

practitioner will lose confidence in the treatment, and even CM as a

whole. But if the person has confidence through their training, then

they are not afraid to tackle the tough stuff, to ask our patient to

wait for outcomes, and are skilled enough to understand why change may

not be happening the way they thought, and they can communicate this

to the client.

For example, I have been treating a patient with psoriasis for the

past several months. He has not been getting better as quickly as I

would have liked and he himself is actually starting to lose

confidence. So I can look at his case and understand why. Firstly he

presents with psoriasis on his palms- which from a prognosis point of

view is not very good. It shows that there is more fire toxins present

and that the lesion will be harder to treat.

Secondly the patient drinks a lot of wine, he tells me " well if your

out with your friends and you are drinking good hundred dollar bottles

of wine, it is not so easy to stop! " Well I have to inform him that

alcohol, out of anything thing he can do for himself is the absolute

worse for psoriasis. That by him drinking so much, we are just

outdoing any good I may do with the herbs.

Lastly, i have been using E Feng granule herbs. The dosages I have

been taught to use to obtain good results with psoriasis are in the

180 grams per day region. Maybe the granules lack that power punch.

This is certainly Mazin's thinking, as he only uses raw herbs,

pressure cooked and packaged for the patient. i have to admit that I

do have many other clients whose psoriasis has improved by the use of

the granules, so maybe they are not as effective in the more stubborn

cases. It is hard to know for sure.

Anyways, through a thorough understanding of how to approach the

problem before us, based on the wisdom of our teachers, we can know if

our treatments are effective or not. Sure the changing of the seasons

can play a role, but if we know that if they take our herbs for such

and such amount of time and the change we see happens within that

amount of time, then we can have deeper faith that our treatments are

effective. That it was through our help that the patient got better.

Proper training helps to remove the guess work. It allows the true

power of our medicine to do its job. Chinese medicine has lots of

proof behind its pudding. I do not know about all these other systems,

and I am always leary until I can see, for myself, proper healing.

What is the saying, " If we dig a thousand shallow wells we may never

find water, but if we dig one deep well then our chances of finding

water are a lot greater. "

I have no problem in using a herb because of the western thought

behind it, but for me the main DX and formula written has to be based

on CM. Other wise I am lost in the dark and I am playing russian

roulette. Saying a herb is good for psoriasis is not good enough, one

has to explain to me how this herb addresses this type of pattern, as

seen in psoriasis.

Trevor

February 15, 2008

Thank you for sharing your experience with me. It is very helpful. I had the

same kind of a problem you describe with a Polish concert pianist who loved

his cognac, vodka or wine in the late evenings. He developed bleeding

psoriasis on his hands and his scalp was peeling and flaking -- he was not a

happy camper. I gave him the right herbs and to the extent he'd follow my

protocol he would begin to improve but the slightest amount of alcohol and

the entire thing was undone. He wanted fast results. Honestly, not having

the benefit of your excellent training, I could not assure him how long it

might take for him to improve and so each week we'd be looking for results

and because of his drinking they were very measured.

You know, so many who have responded on this list seem to object to thinking

or using methods and herbs that are not part of what they learned however,

when I wrote Planetary Herbology integrating herbs from around the world

into CM I found that herbs are not Chinese, western, Indian and know not

limited to our narrow preferences. I wonder how many people realize how many

tons of American ginseng was exported on 17th and 18th century boats from

the eastern seaboard. Daniel Boone was a ginseng hunter and he had 2 or 3

tons of ginseng on a raft on the river headed for export to China when it

overturned and all of it was lost.

Many of the common herbs used in the west and around the world such as

chickweed, Malva, burdock root, Malva, dandelion, species of sarsaparilla,

etc are described in terms of their properties and natures in Li Shi Zhen's

books, in the Barefoot Doctor Manual and in a wonderful set of books

published several years ago called the Herbs of Hong Kong. Today many

Chinese herbalists here and in China prefer to use such herbs based on their

local customs.

Heat clearing herbs are the most reliable, second to laxatives of course, of

all Western herbs and you can give a reasonable dose of the granules and

also have them take a tea comprised of red clover blossoms, dandelion root,

burdock root, sarsaparilla for instance -- all known to be very effective

for psoriasis and eczema with an underlying pattern of heat. If there is yin

deficiency that's when you have to supplement with Chinese herbs.

Anyway, I really appreciate hearing the approximate times it takes for

treatment to resolve the skin conditions you mentioned.

Michael Tierra

WWW.planetherbs.com

_____

February 15, 2008

Trevor if your patients are willing to wait that long you are lucky. If i do not

get real changes in most of my patient in 1-3 wk its very unlikely i would see

them again

February 15, 2008

On Fri, Feb 15, 2008 at 9:33 AM, Alon Marcus <alonmarcus wrote:

> Trevor if your patients are willing to wait that long you are lucky. If

> i do not get real changes in most of my patient in 1-3 wk its very unlikely

> i would see them again

>

I'm glad you said that, Alon. This has been my experience as well.

I have seen how some practitioners offer a certain narrative during

treatments that can keep a patient coming in for longer. Things like

expressing perceptions of progress even though they may be limited to signs

that the practitioner alone can see. I'm not suggesting this is wrong or

bad, just an observation.

For many practitioners, what we do is primarily an entrepreneurial activity

rather than medical. For others, it is mostly a medical issue. Those who are

better at selling their services can keep patients around for longer than

those who may actually be better with clinical outcomes.

These are two very different skill sets which are best harmonized by both

medical and business ethics.

--

, DAOM

Pain is inevitable, suffering is optional.

February 15, 2008

Alon,

I am talking in specific to chronic skin disease. If I use external

tx then the results may be quicker.

I think the length of time a treatment may take depends on the

problem being treated. This is the whole point about be skilled in

the areas appropriate to what we are treating in clinic.

Even in Gyno, ie painful mense, I may need 2-3 cycles before the

patient sees a good change.

Trevor

, " Alon Marcus "

<alonmarcus wrote:

>

> Trevor if your patients are willing to wait that long you are

lucky. If i do not get real changes in most of my patient in 1-3 wk

its very unlikely i would see them again

>

February 15, 2008

Al,

Narrative is important. I am very comfortable with being upfront

about treatment expectations. If a patient isn't willing to wait it

out for proper results, I tell them straight up that they CANNOT say

chinese medicine didn't work for them because they did not comply

with treatment.

Compliance to treatment is not just about getting someone to take

their daily dose of herbs, it is also being clear to them about

treatment time. This is purely clinical experience. I have seen many

practitioners give up on their patients themselves after only 1-2

weeks of treatment, saying to the patient that CM problably won't

work for them.

If a patient comes in with an absent menstruation, do you think they

will see some positive sign that it is going to return in only 1-2

weeks!!?? For these patients, depending on their FSH levels and other

factors, I let them know they will probably have to try for at least

6 months, if not longer.

It is not just about entrepreneurialship, it is about knowing what to

expect with our treatments in conjunction with a good understanding

of the disease or pattern that we are treating. There is no majic

pill for any problem. I think we have be wise about our expectiations

and educate the patient appropriately.

Trevor

, " Al Stone " <al wrote:

>

> On Fri, Feb 15, 2008 at 9:33 AM, Alon Marcus <alonmarcus wrote:

>

> > Trevor if your patients are willing to wait that long you are

lucky. If

> > i do not get real changes in most of my patient in 1-3 wk its

very unlikely

> > i would see them again

> I'm glad you said that, Alon. This has been my experience as well.

>

> I have seen how some practitioners offer a certain narrative during

> treatments that can keep a patient coming in for longer. Things like

> expressing perceptions of progress even though they may be limited

to signs

> that the practitioner alone can see. I'm not suggesting this is

wrong or

> bad, just an observation.

>

> For many practitioners, what we do is primarily an entrepreneurial

activity

> rather than medical. For others, it is mostly a medical issue.

Those who are

> better at selling their services can keep patients around for

longer than

> those who may actually be better with clinical outcomes.

>

> These are two very different skill sets which are best harmonized

by both

> medical and business ethics.

>

> --

> , DAOM

> Pain is inevitable, suffering is optional.

>

February 15, 2008

I agree with Trevor. It is not uncommon to hear (in China) experienced

practitioners say, your problem will take 6 months (or 1-2 years) to see

results / cure. One must know the disease and read the patient. Obviously

though most conditions should show some sign of improvement somewhere

(usually secondary signs). Although it is interesting that the doctors I

have studied with many times do not even mention this. Everyone has their

style. Since many people that we see have entrenched complex problems, one

must know how long these will take, and communicate this honestly.

My 2 cents.

-Jason

_____

On Behalf Of Trevor Erikson

Friday, February 15, 2008 11:21 AM

Re: Outcome Measurements,

Al,

Narrative is important. I am very comfortable with being upfront

about treatment expectations. If a patient isn't willing to wait it

out for proper results, I tell them straight up that they CANNOT say

chinese medicine didn't work for them because they did not comply

with treatment.

Compliance to treatment is not just about getting someone to take

their daily dose of herbs, it is also being clear to them about

treatment time. This is purely clinical experience. I have seen many

practitioners give up on their patients themselves after only 1-2

weeks of treatment, saying to the patient that CM problably won't

work for them.

If a patient comes in with an absent menstruation, do you think they

will see some positive sign that it is going to return in only 1-2

weeks!!?? For these patients, depending on their FSH levels and other

factors, I let them know they will probably have to try for at least

6 months, if not longer.

It is not just about entrepreneurialship, it is about knowing what to

expect with our treatments in conjunction with a good understanding

of the disease or pattern that we are treating. There is no majic

pill for any problem. I think we have be wise about our expectiations

and educate the patient appropriately.

Trevor

@ <%40>

, " Al Stone " <al wrote:

>

> On Fri, Feb 15, 2008 at 9:33 AM, Alon Marcus <alonmarcus wrote:

>

> > Trevor if your patients are willing to wait that long you are

lucky. If

> > i do not get real changes in most of my patient in 1-3 wk its

very unlikely

> > i would see them again

> I'm glad you said that, Alon. This has been my experience as well.

>

> I have seen how some practitioners offer a certain narrative during

> treatments that can keep a patient coming in for longer. Things like

> expressing perceptions of progress even though they may be limited

to signs

> that the practitioner alone can see. I'm not suggesting this is

wrong or

> bad, just an observation.

>

> For many practitioners, what we do is primarily an entrepreneurial

activity

> rather than medical. For others, it is mostly a medical issue.

Those who are

> better at selling their services can keep patients around for

longer than

> those who may actually be better with clinical outcomes.

>

> These are two very different skill sets which are best harmonized

by both

> medical and business ethics.

>

> --

> , DAOM

> Pain is inevitable, suffering is optional.

>

February 15, 2008

Hey Michael!

Thank as well for sharing your experiences with psoriasis, especially

as it relates to alcohol.

I am in total agreement with you when it comes to using local western

herbs. As I have mentioned in previous posts, I trained with our great

Canadian western herbalist, Terri Willard back in 1991 or so. From

there it was off to the bush for many years raising a family while

living in Teepees and wildcrafting the wild plants.

It was actually Plantetary herbalogy that helped me bridge over to

study chinese medicine. I am greatful to you for this.

I geuss for me now, it is learning how to properly judge what herbs

are needed and which ones can wait. Learning how to keep my numbers

down and be effective. Learning how to truly understand the minor

indications for a specific herb.

Lets take Pu Ging Ying, dandelion, as an example. Many people know

that it is a fire Toxin resolver and that it is very useful for skin

disease. So in my training, I was taught that the only real useful

place for this herb when treating psoriasis is in the treatment of

pustular psoriasis, which is actually a rarer form of psoriasis. So in

other words, it is better to fill up the Rx with herbs that are going

to be more useful. Just because dandelion has been listed as a herb

that is good for skin disease does not mean it is good for all skin

problems. Actually dandelion is best used in cases of acne or eczema

when there are lots of vesicles or pustules present.

Then there is the herb Bai Zhi (sorry I cannot remember the common or

latin name). This herb has been found through modern research to slow

the growth of the hyperactive skin cells which is the main mechanism

behind psoriasis. So obviously a very useful herb for psoriasis, but I

was taught and have seen in clinic that this herb is actually best

reserved for psoriasis when it is really itchy. Obviously because of

its wind scattering ability.

So what I meaning is that by truly understanding the depth of one

system of thought, can help me narrow down my herbal choices, so that

I am only picking the most effective ones for the presenting case. Not

just throwing a bunch of herbs into a pot because they have been shown

to be good for any particular problem.

I would love to only use local herbs in my practice, but I have found

that they have not been classified as deeply as the chinese herbs and

there needs to be more experience of this brought to the table. The

depth and variance between the heat clearing herbs is massive. And

even more so as we become more and more specific, as in the fore toxin

resolvers. Does the herb work like Jin Yin Hua, which helps clear heat

from the superficial levels of the skin, or does the herb clear heat

like Pu Gong Ying which is working on the more deeper levels of the

skin, helping to absorb the toxin and then purge it out.

Trevor

, " Michael Tierra "

<mtierra wrote:

>

> Thank you for sharing your experience with me. It is very helpful. I

had the

> same kind of a problem you describe with a Polish concert pianist

who loved

> his cognac, vodka or wine in the late evenings. He developed bleeding

> psoriasis on his hands and his scalp was peeling and flaking -- he

was not a

> happy camper. I gave him the right herbs and to the extent he'd

follow my

> protocol he would begin to improve but the slightest amount of

alcohol and

> the entire thing was undone. He wanted fast results. Honestly, not

having

> the benefit of your excellent training, I could not assure him how

long it

> might take for him to improve and so each week we'd be looking for

results

> and because of his drinking they were very measured.

>

> You know, so many who have responded on this list seem to object to

thinking

> or using methods and herbs that are not part of what they learned

however,

> when I wrote Planetary Herbology integrating herbs from around the world

> into CM I found that herbs are not Chinese, western, Indian and know not

> limited to our narrow preferences. I wonder how many people realize

how many

> tons of American ginseng was exported on 17th and 18th century boats

from

> the eastern seaboard. Daniel Boone was a ginseng hunter and he had 2

or 3

> tons of ginseng on a raft on the river headed for export to China

when it

> overturned and all of it was lost.

>

> Many of the common herbs used in the west and around the world such as

> chickweed, Malva, burdock root, Malva, dandelion, species of

sarsaparilla,

> etc are described in terms of their properties and natures in Li

Shi Zhen's

> books, in the Barefoot Doctor Manual and in a wonderful set of books

> published several years ago called the Herbs of Hong Kong. Today many

> Chinese herbalists here and in China prefer to use such herbs based

on their

> local customs.

>

> Heat clearing herbs are the most reliable, second to laxatives of

course, of

> all Western herbs and you can give a reasonable dose of the granules and

> also have them take a tea comprised of red clover blossoms,

dandelion root,

> burdock root, sarsaparilla for instance -- all known to be very

effective

> for psoriasis and eczema with an underlying pattern of heat. If

there is yin

> deficiency that's when you have to supplement with Chinese herbs.

>

> Anyway, I really appreciate hearing the approximate times it takes for

> treatment to resolve the skin conditions you mentioned.

>

> Michael Tierra

> WWW.planetherbs.com

>

> _____

>

February 15, 2008

Michael,

Here is my perspective on your question. I think we all agree that China has

incorporated many herbs from around the world into their arsenal. Although

they had to figure out the properties like anyone else, they do have many

advantages over us in determining this data. Their clinical opportunities (1

doctor may see 100-200 people a day), the mass number of doctors, and the

immense amount of theory to guide them are something we just do not have

here. Since they do not blindly determine an herb's nature, we see that it

takes years and years of work (by many people). One can see quite clearly

that our modern understanding of herbs has evolved through 100's-1000's of

years of trial and error. Now if an herb is only mentioned in one source

(even by Li Shi-Zhen) and no one uses it, then IMO it is not that useful.

The description in the MM is only about 20% of the herb data. One must see

it in action (i.e. case studies, formulas etc) to really understand how to

use it.

Why can't we just figure out the data here in the States? When the average

practitioner probably sees less than 20 people a week, we are at a major

disadvantage for evaluating 'new' herbs within a CM framework. Finally as

has been pointed out numerous times, I believe most of us do not even have a

solid foundational understanding (of CM) that would lay the ground for a

more innovative type of thinking. How can I trust that we even figure the

herbs out correctly? Let alone how they interact in conjunction with other

herbs. Chinese medicine formulas are built on herbal combinations. This

takes years to develop.

There are just way too many variable in the mix for me (personally) to start

throwing 'unknown' herbs into my formulas. Although I acknowledge that we

need and should develop this aspect of the medicine, especially

incorporating local medicinals, I just don't see how I could at this point

in time. I am still trying to learn CM as it is. For example, if I want to

go deeper into how to use xing ren, I can read ZhangJi, Ding gan ren, Ye

Tian-Shi, Qin Bo-wei (etc). All broadening my view and enabling me to use it

more effectively with other herbs. If I want to understand sarsaparilla, how

could I do this? I could start experimenting with it in my formulas.?? No

thanks. If you have ever tried to figure out what 1 herb is really doing in

a formula, and haven't most of the time just ended up scratched your head,

then please tell me the secret.

I know it is not the most environmentally sound idea to ship herbs around

the world for my formulas, but I do understand the nature of the herbs I am

giving fairly well. And if I don't (as mentioned above) I can read plenty of

sources to help me, from people that have seen more patients in a year that

I will probably in my life-time. I also know how they interact with other

herbs, and most of these herbs have 100's and 100's of years of history

backing them up. So you ask why we don't jump on the wagon. That is my

answer.

I am curious how other justify there use of integrating such unknowns???

But back to Michael's idea. I would love to here some more info on some of

these common herbs that Michael mentions. For me personally to be able to

use it, I would need to see a monograph that included not only some Chinese

MM entries but formulas that it appears in and then case studies that use

it. Since I do not know where this information is, I find it hard act on

this level..

Thoughts??

-

_____

On Behalf Of Michael Tierra

Friday, February 15, 2008 3:21 AM

RE: Re: Outcome Measurements,