Pattern Identification

August 14, 2008

Dear Members,

How many sign and symptoms does it take to make a match in terms of

pattern diagnosis?

I believe one professor said 2-3. Is this congruent with your

understanding and clinical experience.

I have been observing a lot of practitioners since graduating 2 years

ago. Some focus on 1-3 patterns at a time, others are using massive

formulas a treating 3-8 patterns at a time. I understand the theory of

both styles but what is the concensus regarding these approaches among

CHA members. They seem dramatically different, with significantly

different results. I'm not talking about acute vs. chronic conditions

here.

Please help shed some light on this with the emphasis being on

clinical experience and results...not overly theoretical.

Thank you for any help with this.

Cheers,

Dave Vitello

August 14, 2008

Dave,

I think this is a very worthwhile and important question for both the

Western and Chinese world. Because of this, I have thought about this issue

for many years and actually wrote an extensive essay on the topic, but never

published it.

In my opinion, diagnosing 3-8 patterns is usually a result of sloppy and

unclear diagnosis. Furthermore, I can't recall any Chinese literature (at

least that I have read) that supports this style. I would bet money that

these larger diagnoses are coming from either students / recent graduates or

poorly trained practitioners. Many times these are Westerners, but also I

have seen younger Chinese that have received shabby educations, i.e.

replacing essential CM fundaments with modern " Western science " and ending

up with a fairly poor understand of both. This is common in many modern

larger institutions.

Maybe you could give us some examples of cases or formulas.

Personally, while observing old Chinese master herbalists, I have seen them

take a seemingly complex case and zone in on the key point(s) and address it

clearly. The same case, viewed my many Westerners, many times would result

in formulas that are unclear and unfocused, treating as you say, 5+

patterns. Although I have seen cases where these complex approaches work. I

have also seen them fail more times than not. Furthermore, when prescribing

with such a complex style it makes it extremely difficult to troubleshoot

side-effects or errors when the formula does not work 100%.

This is not to say one can't do multiple things in a formula. This type of

fine-tuning is normal for addressing the individual. But there is a certain

clarity of thought that one can see in a formula with a clear diagnosis

(that may attend to multiple aspects) and one that tries to treat 5+

patterns simultaneously. One should look through the most famous formulas

(i.e. in Formulas and Strategies) and see how many patterns these formulas

usually treat. Such formulas are representative of the MOST common scenarios

that one will find in the clinic. Of course modifications are necessary, but

that does not mean add another 3 patterns to it.

Besides physically watching Chinese doctors prescribe, I also have read a

large amount of traditional, pre-modern, and modern case studies. I have yet

to find one case study that says that it addresses more than three patterns.

Therefore, I would guess that 95-99% of all famous cases do not treat more

than 3 patterns. This, in and of itself, speaks directly to the clinical

experience of the brightest doctors in CM, not just some guy (like myself)

typing on the CHA.

As for how many signs or symptoms one needs to make a diagnosis. This is

more difficult and all depends on the presentation.

But recently I heard a few people talking about a list of signs and symptoms

that when present will always refer to a single diagnosis (by themselves).

Although this has been discussed previously on the CHA, if people want to

present some of these I think it is always worthwhile looking at the variety

of perspectives that one can interpret such a " symptom " . I personally do not

buy this type of thinking. And believe that such an approach may seem to

provide diagnostic clarity; it also will inevitably lead to clinical

blunders.

My 2 cents,

-

_____

On Behalf Of dmvitello01

Thursday, August 14, 2008 11:51 AM

Pattern Identification

Dear Members,

How many sign and symptoms does it take to make a match in terms of

pattern diagnosis?

I believe one professor said 2-3. Is this congruent with your

understanding and clinical experience.

I have been observing a lot of practitioners since graduating 2 years

ago. Some focus on 1-3 patterns at a time, others are using massive

formulas a treating 3-8 patterns at a time. I understand the theory of

both styles but what is the concensus regarding these approaches among

CHA members. They seem dramatically different, with significantly

different results. I'm not talking about acute vs. chronic conditions

here.

Please help shed some light on this with the emphasis being on

clinical experience and results...not overly theoretical.

Thank you for any help with this.

Cheers,

Dave Vitello

August 14, 2008

Jason,

I find this a bit perplexing, seeing as many patients do manifest

in complex patterns, especially in diseases such as cancer. CM

oncologists such as Sun Bing-yin routinely use 20-30 medicinals in

prescriptions, with groups of herbs to supplement qi and blood, toxic

medicinals to dislodge cancer toxins, cathartic purgatives and

precipitating medicinals to clear cancer toxin through the bowels,

herbs to warm the yang, etc.

We've already discussed Li Dong-yuan prescriptions in the past,

which are also fairly complex, but they are cohesive in terms of

pattern identification with spleen/stomach vacuities or disharmonies

at the enter. So this may not be what you are referring to here. .

On Aug 14, 2008, at 4:19 PM, wrote:

> In my opinion, diagnosing 3-8 patterns is usually a result of sloppy

> and

> unclear diagnosis. Furthermore, I can't recall any Chinese

> literature (at

> least that I have read) that supports this style. I would bet money

> that

> these larger diagnoses are coming from either students / recent

> graduates or

> poorly trained practitioners. Many times these are Westerners, but

> also I

> have seen younger Chinese that have received shabby educations, i.e.

> replacing essential CM fundaments with modern " Western science " and

> ending

> up with a fairly poor understand of both. This is common in many

> modern

> larger institutions.

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

August 14, 2008

signs and symptoms aren't so much rated in terms of numbers, but by their

importance.

For instance, there are several causes for chronic constipation with hard

dry stools.

yin xu & blood xu

So, then its just a quick look at the tongue for pale vs. red to

differentiate the yin xu from the blood xu.

So, there's the chief complaint plus one other sign to look at.

Other complaints require much more triangulation, but I can differentiate in

as few as two, as seen above. I'm not saying that the pulse wouldn't provide

a much more detailed story behind the presentation, nor do I suggest that

one should ignore the ten questions, etc... but when I'm diagnosing, I try

and focus on those signs and symptoms that break ties rather than muddy up

the water with additional possibilities.

In my first year, I worked in a clinic where I was fed four patients per

hour and I got real good at quick differentiations using the logic described

above. It helps to focus on the chief complaint, translate that into

symptoms if necessary (since many people's chief complaints are really

someone else's diagnosis, not complaints).

As for what Jason talked about with the excessive diagnosis in beginners, I

couldn't agree more. I see it often in the teaching clinic or on some

mailing lists. The problem being exactly like what I wrote above, the

beginner would provide every possible reason for constipation such as yin

and blood deficiency, qi and blood stagnation, and usually some kidney

deficiency. No focus. No insight. No good results.

-al.

On Thu, Aug 14, 2008 at 10:50 AM, dmvitello01 <dmvitello wrote:

> Dear Members,

>

> How many sign and symptoms does it take to make a match in terms of

> pattern diagnosis?

>

> I believe one professor said 2-3. Is this congruent with your

> understanding and clinical experience.

>

> I have been observing a lot of practitioners since graduating 2 years

> ago. Some focus on 1-3 patterns at a time, others are using massive

> formulas a treating 3-8 patterns at a time. I understand the theory of

> both styles but what is the concensus regarding these approaches among

> CHA members. They seem dramatically different, with significantly

> different results. I'm not talking about acute vs. chronic conditions

> here.

>

> Please help shed some light on this with the emphasis being on

> clinical experience and results...not overly theoretical.

>

> Thank you for any help with this.

> Cheers,

> Dave Vitello

>

--

, DAOM

Pain is inevitable, suffering is optional.

August 14, 2008

Al,

I've seen the same tendency. There is no doubt that one of the great

weaknesses in our profession and schools is teaching people how to

diagnose correctly. However, my point to Jason was that we shouldn't

forget that there are traditions such as the spleen/stomach school

that do use a more complex pattern differentiation than standard CM.

On Aug 14, 2008, at 4:57 PM, Al Stone wrote:

> As for what Jason talked about with the excessive diagnosis in

> beginners, I

> couldn't agree more. I see it often in the teaching clinic or on some

> mailing lists. The problem being exactly like what I wrote above, the

> beginner would provide every possible reason for constipation such

> as yin

> and blood deficiency, qi and blood stagnation, and usually some kidney

> deficiency. No focus. No insight. No good results.

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

August 14, 2008

Z'ev,

I do agree but think these cancer treatments are the exception not the rule.

I do though, leave much room for the exceptions. However, I think what we

are discussing here are the average patients that walk through our doors and

how a practitioner views things. As mentioned you may see a complex patient

with 8 patterns, where someone else may see only 2 or 3. This may be a

preference, but as previously mentioned, we cannot forget that the majority

of case records do not support this approach. However, I noticed this trend

very early when I was in school. The more serious Chinese supervisors could

zero in on 2 principle ideas, where a previous practitioner (usually a less

educated westerner) might have written in 5+ patterns. I knew then, that

this topic must be investigated further.

In my clinic I treat very " complex " patients (autoimmune etc.) however; I do

not find 5+ patterns. It is all in one's perspective. My main teacher in

China also treats very " complex " cases, more severe that most patients we

see in our clinics. He is always very clear in diagnosis and treatment. And

essentially I am just parroting him, because he always says the same thing.

I do acknowledge, though, that there are traditions and practitioners that

like to prescribe 20-30+ ingredients or 5-8 patterns. One can see it in any

major hospital in China. There are many reasons this is done, one major one

being, financial. I just do not agree that this is a necessity and have a

hard time gaining any major insights from this approach. Throwing multiple

categories of herbs at people just seems sloppy.

I am curious for the many people that have studied with such doctors. How do

you learn from these formulas? Can you extrapolate clear CM ideas?

Although LDY's formula may be more complex then some, as you point out, they

represent fairly straightforward cohesive thought processes. I still do not

view them as treating 5+ patterns. Do you?

Finally, the older doctor's that I have observed who are known as " spleen

and stomach school practitioners " have always very clear in their approach.

I do acknowledge that this more " simple style " is one that I like and have

just not been interested in following those modern young doctors who write

giant formulas. However, with it comes clarity that is hard to find when

formulas are all over the place. Not to mention, I have seen more people get

sick from such formulas than other styles.

-

_____

On Behalf Of

Thursday, August 14, 2008 5:50 PM

Re: Pattern Identification

Jason,

I find this a bit perplexing, seeing as many patients do manifest

in complex patterns, especially in diseases such as cancer. CM

oncologists such as Sun Bing-yin routinely use 20-30 medicinals in

prescriptions, with groups of herbs to supplement qi and blood, toxic

medicinals to dislodge cancer toxins, cathartic purgatives and

precipitating medicinals to clear cancer toxin through the bowels,

herbs to warm the yang, etc.

We've already discussed Li Dong-yuan prescriptions in the past,

which are also fairly complex, but they are cohesive in terms of

pattern identification with spleen/stomach vacuities or disharmonies

at the enter. So this may not be what you are referring to here. .

On Aug 14, 2008, at 4:19 PM, wrote:

> In my opinion, diagnosing 3-8 patterns is usually a result of sloppy

> and

> unclear diagnosis. Furthermore, I can't recall any Chinese

> literature (at

> least that I have read) that supports this style. I would bet money

> that

> these larger diagnoses are coming from either students / recent

> graduates or

> poorly trained practitioners. Many times these are Westerners, but

> also I

> have seen younger Chinese that have received shabby educations, i.e.

> replacing essential CM fundaments with modern " Western science " and

> ending

> up with a fairly poor understand of both. This is common in many

> modern

> larger institutions.

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

August 14, 2008

In a way I'm addressing both of Jason's posts. I'm not so concerned

with multiple diagnosis and more with prioritizing the different

actions of the illness. And perhaps I'm missing the term diagnosis but

for example I can look at a patient with both damp and Yin Xu. I put

this to students and they get irate. :-) So how can I explain that

the damp is blocking Yin from circulating? Yin Xu is " supposed " to be

deeper than damp so a really good practitioner would go for the

" root " , Right?

So you know where I am going.... If we clear the damp we can see the

extent of the Yin Xu. Was it a cause or was it a manifestation? That's

where the " school " comes in and where a simple and cursory examination

of the herbal formula falls short.

So when we have 5 " things going on " , (Yin Xu, blood stasis, damp

etc...) are we really saying 5 diagnosis or 5 manifestations? Of

course , the really good practitioner will zone in on the key to all

the above and make that a central and hopefully, elegant, diagnosis.

Doug

, " "

wrote:

>

> Z'ev,

>

> I do agree but think these cancer treatments are the exception not

the rule.

> I do though, leave much room for the exceptions. However, I think

what we

> are discussing here are the average patients that walk through our

doors and

> how a practitioner views things. As mentioned you may see a complex

patient

> with 8 patterns, where someone else may see only 2 or 3. This may be a

> preference, but as previously mentioned, we cannot forget that the

majority

> of case records do not support this approach. However, I noticed

this trend

> very early when I was in school. The more serious Chinese

supervisors could

> zero in on 2 principle ideas, where a previous practitioner (usually

a less

> educated westerner) might have written in 5+ patterns. I knew then, that

> this topic must be investigated further.

>

> In my clinic I treat very " complex " patients (autoimmune etc.)

however; I do

> not find 5+ patterns. It is all in one's perspective. My main teacher in

> China also treats very " complex " cases, more severe that most

patients we

> see in our clinics. He is always very clear in diagnosis and

treatment. And

> essentially I am just parroting him, because he always says the same

thing.

>

> I do acknowledge, though, that there are traditions and

practitioners that

> like to prescribe 20-30+ ingredients or 5-8 patterns. One can see it

in any

> major hospital in China. There are many reasons this is done, one

major one

> being, financial. I just do not agree that this is a necessity and

have a

> hard time gaining any major insights from this approach. Throwing

multiple

> categories of herbs at people just seems sloppy.

>

> I am curious for the many people that have studied with such

doctors. How do

> you learn from these formulas? Can you extrapolate clear CM ideas?

>

> Although LDY's formula may be more complex then some, as you point

out, they

> represent fairly straightforward cohesive thought processes. I still

do not

> view them as treating 5+ patterns. Do you?

>

> Finally, the older doctor's that I have observed who are known as

" spleen

> and stomach school practitioners " have always very clear in their

approach.

> I do acknowledge that this more " simple style " is one that I like

and have

> just not been interested in following those modern young doctors who

write

> giant formulas. However, with it comes clarity that is hard to find when

> formulas are all over the place. Not to mention, I have seen more

people get

> sick from such formulas than other styles.

>

> -

>

_____

>

> On Behalf Of

> Thursday, August 14, 2008 5:50 PM

>

> Re: Pattern Identification

>

> Jason,

> I find this a bit perplexing, seeing as many patients do manifest

> in complex patterns, especially in diseases such as cancer. CM

> oncologists such as Sun Bing-yin routinely use 20-30 medicinals in

> prescriptions, with groups of herbs to supplement qi and blood, toxic

> medicinals to dislodge cancer toxins, cathartic purgatives and

> precipitating medicinals to clear cancer toxin through the bowels,

> herbs to warm the yang, etc.

>

> We've already discussed Li Dong-yuan prescriptions in the past,

> which are also fairly complex, but they are cohesive in terms of

> pattern identification with spleen/stomach vacuities or disharmonies

> at the enter. So this may not be what you are referring to here. .

>

> On Aug 14, 2008, at 4:19 PM, wrote:

>

> > In my opinion, diagnosing 3-8 patterns is usually a result of sloppy

> > and

> > unclear diagnosis. Furthermore, I can't recall any Chinese

> > literature (at

> > least that I have read) that supports this style. I would bet money

> > that

> > these larger diagnoses are coming from either students / recent

> > graduates or

> > poorly trained practitioners. Many times these are Westerners, but

> > also I

> > have seen younger Chinese that have received shabby educations, i.e.

> > replacing essential CM fundaments with modern " Western science " and

> > ending

> > up with a fairly poor understand of both. This is common in many

> > modern

> > larger institutions.

>

> Chair, Department of Herbal Medicine

> Pacific College of Oriental Medicine

> San Diego, Ca. 92122

>

August 14, 2008

Doug,

I totally agree. However, of course as you say, one may have yin xu or fluid

xu (signs and symptoms) from damp (as the root). I do not think that yin xu

is deeper. I think you agree. Therefore just clearing the root damp can

alleviate the fluid xu. Your example is precisely the point. IMO, it would

be a mistake to diagnosis yin xu (therefore tonify yin) even though they may

have dry skin, dry mouth, etc.

I do agree, though, that there are situations where you need to do both at

the same time, but this is a different issue.

-Jason

_____

On Behalf Of

Thursday, August 14, 2008 8:23 PM

Re: Pattern Identification

In a way I'm addressing both of Jason's posts. I'm not so concerned

with multiple diagnosis and more with prioritizing the different

actions of the illness. And perhaps I'm missing the term diagnosis but

for example I can look at a patient with both damp and Yin Xu. I put

this to students and they get irate. :-) So how can I explain that

the damp is blocking Yin from circulating? Yin Xu is " supposed " to be

deeper than damp so a really good practitioner would go for the

" root " , Right?

So you know where I am going.... If we clear the damp we can see the

extent of the Yin Xu. Was it a cause or was it a manifestation? That's

where the " school " comes in and where a simple and cursory examination

of the herbal formula falls short.

So when we have 5 " things going on " , (Yin Xu, blood stasis, damp

etc...) are we really saying 5 diagnosis or 5 manifestations? Of

course , the really good practitioner will zone in on the key to all

the above and make that a central and hopefully, elegant, diagnosis.

Doug

@ <%40>

, " "

wrote:

>

> Z'ev,

>

> I do agree but think these cancer treatments are the exception not

the rule.

> I do though, leave much room for the exceptions. However, I think

what we

> are discussing here are the average patients that walk through our

doors and

> how a practitioner views things. As mentioned you may see a complex

patient

> with 8 patterns, where someone else may see only 2 or 3. This may be a

> preference, but as previously mentioned, we cannot forget that the

majority

> of case records do not support this approach. However, I noticed

this trend

> very early when I was in school. The more serious Chinese

supervisors could

> zero in on 2 principle ideas, where a previous practitioner (usually

a less

> educated westerner) might have written in 5+ patterns. I knew then, that

> this topic must be investigated further.

>

> In my clinic I treat very " complex " patients (autoimmune etc.)

however; I do

> not find 5+ patterns. It is all in one's perspective. My main teacher in

> China also treats very " complex " cases, more severe that most

patients we

> see in our clinics. He is always very clear in diagnosis and

treatment. And

> essentially I am just parroting him, because he always says the same

thing.

>

> I do acknowledge, though, that there are traditions and

practitioners that

> like to prescribe 20-30+ ingredients or 5-8 patterns. One can see it

in any

> major hospital in China. There are many reasons this is done, one

major one

> being, financial. I just do not agree that this is a necessity and

have a

> hard time gaining any major insights from this approach. Throwing

multiple

> categories of herbs at people just seems sloppy.

>

> I am curious for the many people that have studied with such

doctors. How do

> you learn from these formulas? Can you extrapolate clear CM ideas?

>

> Although LDY's formula may be more complex then some, as you point

out, they

> represent fairly straightforward cohesive thought processes. I still

do not

> view them as treating 5+ patterns. Do you?

>

> Finally, the older doctor's that I have observed who are known as

" spleen

> and stomach school practitioners " have always very clear in their

approach.

> I do acknowledge that this more " simple style " is one that I like

and have

> just not been interested in following those modern young doctors who

write

> giant formulas. However, with it comes clarity that is hard to find when

> formulas are all over the place. Not to mention, I have seen more

people get

> sick from such formulas than other styles.

>

> -

>

_____

>

> @ <%40>

> [@ <%40>

] On Behalf Of

> Thursday, August 14, 2008 5:50 PM

> @ <%40>

> Re: Pattern Identification

>

> Jason,

> I find this a bit perplexing, seeing as many patients do manifest

> in complex patterns, especially in diseases such as cancer. CM

> oncologists such as Sun Bing-yin routinely use 20-30 medicinals in

> prescriptions, with groups of herbs to supplement qi and blood, toxic

> medicinals to dislodge cancer toxins, cathartic purgatives and

> precipitating medicinals to clear cancer toxin through the bowels,

> herbs to warm the yang, etc.

>

> We've already discussed Li Dong-yuan prescriptions in the past,

> which are also fairly complex, but they are cohesive in terms of

> pattern identification with spleen/stomach vacuities or disharmonies

> at the enter. So this may not be what you are referring to here. .

>

> On Aug 14, 2008, at 4:19 PM, wrote:

>

> > In my opinion, diagnosing 3-8 patterns is usually a result of sloppy

> > and

> > unclear diagnosis. Furthermore, I can't recall any Chinese

> > literature (at

> > least that I have read) that supports this style. I would bet money

> > that

> > these larger diagnoses are coming from either students / recent

> > graduates or

> > poorly trained practitioners. Many times these are Westerners, but

> > also I

> > have seen younger Chinese that have received shabby educations, i.e.

> > replacing essential CM fundaments with modern " Western science " and

> > ending

> > up with a fairly poor understand of both. This is common in many

> > modern

> > larger institutions.

>

> Chair, Department of Herbal Medicine

> Pacific College of Oriental Medicine

> San Diego, Ca. 92122

>

August 14, 2008

So the question is " what is a diagnosis " ? Of the root, of a pattern of

dysfunction... Should we include a base diagnosis and a branch

diagnosis? Is a diagnosis simply an observation of " something

happening " or is it always the (main) road to treatment?

Doug

, " "

wrote:

>

> Doug,

>

> I totally agree. However, of course as you say, one may have yin xu

or fluid

> xu (signs and symptoms) from damp (as the root). I do not think that

yin xu

> is deeper. I think you agree. Therefore just clearing the root damp can

> alleviate the fluid xu. Your example is precisely the point. IMO, it

would

> be a mistake to diagnosis yin xu (therefore tonify yin) even though

they may

> have dry skin, dry mouth, etc.

>

> I do agree, though, that there are situations where you need to do

both at

> the same time, but this is a different issue.

>

> -Jason

>

> _____

>

> On Behalf Of Douglas

> Thursday, August 14, 2008 8:23 PM

>

> Re: Pattern Identification

>

> In a way I'm addressing both of Jason's posts. I'm not so concerned

> with multiple diagnosis and more with prioritizing the different

> actions of the illness. And perhaps I'm missing the term diagnosis but

> for example I can look at a patient with both damp and Yin Xu. I put

> this to students and they get irate. :-) So how can I explain that

> the damp is blocking Yin from circulating? Yin Xu is " supposed " to be

> deeper than damp so a really good practitioner would go for the

> " root " , Right?

> So you know where I am going.... If we clear the damp we can see the

> extent of the Yin Xu. Was it a cause or was it a manifestation? That's

> where the " school " comes in and where a simple and cursory examination

> of the herbal formula falls short.

> So when we have 5 " things going on " , (Yin Xu, blood stasis, damp

> etc...) are we really saying 5 diagnosis or 5 manifestations? Of

> course , the really good practitioner will zone in on the key to all

> the above and make that a central and hopefully, elegant, diagnosis.

>

> Doug

>

> @ <%40>

> , " "

> <@> wrote:

> >

> > Z'ev,

> >

> > I do agree but think these cancer treatments are the exception not

> the rule.

> > I do though, leave much room for the exceptions. However, I think

> what we

> > are discussing here are the average patients that walk through our

> doors and

> > how a practitioner views things. As mentioned you may see a complex

> patient

> > with 8 patterns, where someone else may see only 2 or 3. This may be a

> > preference, but as previously mentioned, we cannot forget that the

> majority

> > of case records do not support this approach. However, I noticed

> this trend

> > very early when I was in school. The more serious Chinese

> supervisors could

> > zero in on 2 principle ideas, where a previous practitioner (usually

> a less

> > educated westerner) might have written in 5+ patterns. I knew

then, that

> > this topic must be investigated further.

> >

> > In my clinic I treat very " complex " patients (autoimmune etc.)

> however; I do

> > not find 5+ patterns. It is all in one's perspective. My main

teacher in

> > China also treats very " complex " cases, more severe that most

> patients we

> > see in our clinics. He is always very clear in diagnosis and

> treatment. And

> > essentially I am just parroting him, because he always says the same

> thing.

> >

> > I do acknowledge, though, that there are traditions and

> practitioners that

> > like to prescribe 20-30+ ingredients or 5-8 patterns. One can see it

> in any

> > major hospital in China. There are many reasons this is done, one

> major one

> > being, financial. I just do not agree that this is a necessity and

> have a

> > hard time gaining any major insights from this approach. Throwing

> multiple

> > categories of herbs at people just seems sloppy.

> >

> > I am curious for the many people that have studied with such

> doctors. How do

> > you learn from these formulas? Can you extrapolate clear CM ideas?

> >

> > Although LDY's formula may be more complex then some, as you point

> out, they

> > represent fairly straightforward cohesive thought processes. I still

> do not

> > view them as treating 5+ patterns. Do you?

> >

> > Finally, the older doctor's that I have observed who are known as

> " spleen

> > and stomach school practitioners " have always very clear in their

> approach.

> > I do acknowledge that this more " simple style " is one that I like

> and have

> > just not been interested in following those modern young doctors who

> write

> > giant formulas. However, with it comes clarity that is hard to

find when

> > formulas are all over the place. Not to mention, I have seen more

> people get

> > sick from such formulas than other styles.

> >

> > -

> >

> > _____

> >

> > @

<%40>

>

> > [@

<%40>

> ] On Behalf Of

> > Thursday, August 14, 2008 5:50 PM

> > @ <%40>

>

> > Re: Pattern Identification

> >

> > Jason,

> > I find this a bit perplexing, seeing as many patients do manifest

> > in complex patterns, especially in diseases such as cancer. CM

> > oncologists such as Sun Bing-yin routinely use 20-30 medicinals in

> > prescriptions, with groups of herbs to supplement qi and blood, toxic

> > medicinals to dislodge cancer toxins, cathartic purgatives and

> > precipitating medicinals to clear cancer toxin through the bowels,

> > herbs to warm the yang, etc.

> >

> > We've already discussed Li Dong-yuan prescriptions in the past,

> > which are also fairly complex, but they are cohesive in terms of

> > pattern identification with spleen/stomach vacuities or disharmonies

> > at the enter. So this may not be what you are referring to here. .

> >

> > On Aug 14, 2008, at 4:19 PM, wrote:

> >

> > > In my opinion, diagnosing 3-8 patterns is usually a result of

sloppy

> > > and

> > > unclear diagnosis. Furthermore, I can't recall any Chinese

> > > literature (at

> > > least that I have read) that supports this style. I would bet money

> > > that

> > > these larger diagnoses are coming from either students / recent

> > > graduates or

> > > poorly trained practitioners. Many times these are Westerners, but

> > > also I

> > > have seen younger Chinese that have received shabby educations, i.e.

> > > replacing essential CM fundaments with modern " Western science " and

> > > ending

> > > up with a fairly poor understand of both. This is common in many

> > > modern

> > > larger institutions.

> >

> > Chair, Department of Herbal Medicine

> > Pacific College of Oriental Medicine

> > San Diego, Ca. 92122

> >

August 15, 2008

Jason

I do not think its only younger dr that use huge formulas. As i wrote in past

there were 2 very popular old dr in the hospital i worked at (the most popular

out patient dr at the hospital) that used these huge formulas and i am not sure

that they even followed what we call TCM. I tried to follow them but could not

make sense of it and the formulas seemed to based on disease more that patient.

They almost never asked a questions. We are talking about 30 herbs on average.

They saw more patients in a morning than anyone else and had a great reputation

as far as clinical result. They were looked down upon by most of the other Dr

because they never attended school. They were not even made to take the courses

that most other older dr had to take, ie western med for the most part. This

however does not apply to our discussion as see 8 patterns usually mean one

does not apply patho mechanisms to understand secondary and tertiary symptoms

August 15, 2008

Doug,

My off the cuff answer: The diagnosis is what you see as the problem that

you have to deal with at that moment in time to eliminate the symptoms or to

allow you to get to the next layer. One person may name 6 patterns and

another just something a simple as " shaoyang - yangming " . Qin Bo-Wei

actually talks specifically about this. I don't have my Chinese books in

front of me, but he basically says, many people see patients and think they

are complex and don't fit any of the standard patterns and formulas. He says

this is only because they don't have a clear methodology.

The diagnosis should relate directly to your treatment principles and this

should directly relate to you choice of treatment. For example if you

diagnosis yin xu and do not treat it, then this makes little sense to me.

Therefore I do not think a diagnosis is the place to mention mere

observations that we see that are happening (unless directly treated). This

is best reserved for pathomechanisms and discussion.

Furthermore, there are some times where the deepest and root problem is not

addresses right away, therefore naming it as the diagnosis seems illogical.

If one has a straightforward wind attack which is simple addressed by

'diffusing the Lungs and dispersing wind' then it also makes little sense

into diagnosing there underlying patterns.

However, amny times root patterns are essential to acute or branch

treatments. For example, if you have an underlying Liver Yang rising and

have an external attack, it is completely reasonable to diagnosis Liver yang

rising with a wind pathogen on the exterior. Underlying patterns often

affect how we treat acute situations.

I think the biggest issue is, when people name multiple diagnoses it is not

from a complex patient, it is from the inability to understand

pathomechanisms. Meaning, if one believes that nocturia always comes from

Kidney deficiency or if one sees dry mouth, dry skin, and night sweats and

concludes there MUST be yin deficiency without taking into consideration the

whole picture then there may be unnecessary diagnosis.

I think we all agree that this is the major issue.

The clearer my theory has become the clearer I see patients and the simpler

I treat, but that is just me.

Doug (and others) what is your opinion on what diagnosis means to you?

-

_____

On Behalf Of

Thursday, August 14, 2008 9:14 PM

Re: Pattern Identification

So the question is " what is a diagnosis " ? Of the root, of a pattern of

dysfunction... Should we include a base diagnosis and a branch

diagnosis? Is a diagnosis simply an observation of " something

happening " or is it always the (main) road to treatment?

Doug

August 15, 2008

I agree and did not mean to imply that *only* younger doctors prescribe in

this fashion, it is just a trend that I have seen with more biomedically

minded individuals. Many disease based formulas try to treat all possible

major patterns that a disease may come from. (trying to mirror some

research). This, IMO, is set up to fail.

There is of course a long history in CM of specific sects (albeit small) of

doctors using large formulas. It has been the source of much debate

throughout the years. Most of the debate revolves around chaotic

prescribing. Whereas as, as Z'ev has pointed out, LDY's formulas, although

larger, usually get the utmost respect because of the clear and focused

methodology. But in regard to 20-30+ ingredient formulas with large dosages

as Qin Bo-Wei says, " It is just not necessary. "

Granted I think there are many ways to skin a cat, and of course some larger

formulas bring results. But your point about understanding the formula is

the crux. How can one make sense of these giant formulas? I personally don't

even try anymore.

I am though a little confused about your statement below. Are you saying

these doctors got great results? This seems contradictory to your previous

statements, where you said that in China you did follow-ups on all the

patients and never saw good results with Chinese herbs. Have I misunderstood

something?

-Jason

_____

On Behalf Of Alon Marcus

Friday, August 15, 2008 11:23 AM

Re: Pattern Identification

Jason

I do not think its only younger dr that use huge formulas. As i wrote in

past there were 2 very popular old dr in the hospital i worked at (the most

popular out patient dr at the hospital) that used these huge formulas and i

am not sure that they even followed what we call TCM. I tried to follow them

but could not make sense of it and the formulas seemed to based on disease

more that patient. They almost never asked a questions. We are talking about

30 herbs on average. They saw more patients in a morning than anyone else

and had a great reputation as far as clinical result. They were looked down

upon by most of the other Dr because they never attended school. They were

not even made to take the courses that most other older dr had to take, ie

western med for the most part. This however does not apply to our discussion

as see 8 patterns usually mean one does not apply patho mechanisms to

understand secondary and tertiary symptoms

August 15, 2008

Absolutely agree about pathomechanisms. I think its a lot easier for

me in my own clinic than in supervising students. You don't want to

negate their observations yet it takes time to explain pathomechanisms

that they haven't been trained enough in.

Having a methodology also leads one to these " simple " explanations of

most patients having SP ST disharmonies. Or my good friend getting

into Shang Han Lun and using Fu Zi, Gan Jiang treatments for a wide

variety of complaints. These are schools which take a long time to

really appreciate, of course.

I think there is something as " signs of yin xu " but a diagnosis of SP

Qi Xu and Damp.

In answer to the original question, " how many signs do you need to

make a diagnosis? " , I think we would all say only one but it better

be the right one!

Doug

, " "

wrote:

>

> Doug,

>

> I think the biggest issue is, when people name multiple diagnoses it

is not

> from a complex patient, it is from the inability to understand

> pathomechanisms. Meaning, if one believes that nocturia always comes

from

> Kidney deficiency or if one sees dry mouth, dry skin, and night

sweats and

> concludes there MUST be yin deficiency without taking into

consideration the

> whole picture then there may be unnecessary diagnosis.

>

> I think we all agree that this is the major issue.

>

> The clearer my theory has become the clearer I see patients and the

simpler

> I treat, but that is just me.

>

> Doug (and others) what is your opinion on what diagnosis means to you?

>

> -

>

> _____

>

> On Behalf Of Douglas

> Thursday, August 14, 2008 9:14 PM

>

> Re: Pattern Identification

>

> So the question is " what is a diagnosis " ? Of the root, of a pattern of

> dysfunction... Should we include a base diagnosis and a branch

> diagnosis? Is a diagnosis simply an observation of " something

> happening " or is it always the (main) road to treatment?

>

> Doug

>

August 15, 2008

Doug,

How is your friend's success going with his SHL approach?

-Jason

_____

On Behalf Of

Friday, August 15, 2008 9:10 PM

Re: Pattern Identification

Absolutely agree about pathomechanisms. I think its a lot easier for

me in my own clinic than in supervising students. You don't want to

negate their observations yet it takes time to explain pathomechanisms

that they haven't been trained enough in.

Having a methodology also leads one to these " simple " explanations of

most patients having SP ST disharmonies. Or my good friend getting

into Shang Han Lun and using Fu Zi, Gan Jiang treatments for a wide

variety of complaints. These are schools which take a long time to

really appreciate, of course.

I think there is something as " signs of yin xu " but a diagnosis of SP

Qi Xu and Damp.

In answer to the original question, " how many signs do you need to

make a diagnosis? " , I think we would all say only one but it better

be the right one!

Doug

@ <%40>

, " "

wrote:

>

> Doug,

>

> I think the biggest issue is, when people name multiple diagnoses it

is not

> from a complex patient, it is from the inability to understand

> pathomechanisms. Meaning, if one believes that nocturia always comes

from

> Kidney deficiency or if one sees dry mouth, dry skin, and night

sweats and

> concludes there MUST be yin deficiency without taking into

consideration the

> whole picture then there may be unnecessary diagnosis.

>

> I think we all agree that this is the major issue.

>

> The clearer my theory has become the clearer I see patients and the

simpler

> I treat, but that is just me.

>

> Doug (and others) what is your opinion on what diagnosis means to you?

>

> -

>

> _____

>

> @ <%40>

> [@ <%40>

] On Behalf Of Douglas

> Thursday, August 14, 2008 9:14 PM

> @ <%40>

> Re: Pattern Identification

>

> So the question is " what is a diagnosis " ? Of the root, of a pattern of

> dysfunction... Should we include a base diagnosis and a branch

> diagnosis? Is a diagnosis simply an observation of " something

> happening " or is it always the (main) road to treatment?

>

> Doug

>

August 15, 2008

All,

This is such an interesting topic to me. This whole idea of how many

symptoms do you need to make a diagnosis- to create a pattern. And how

to properly read the information given to us. How to properly observe

and look for the correct information to make a diagnosis. All this

while trying to avoid making blanket statements as mentioned above

about yin xu being the only reason for dry mouth and night sweats.

I have only been in actual practice now for three years, but I have

been blessed with having had the opportunity to train with some really

good doctors. I have also been blessed with a current clinical

practice of 60+ people a week, which allows me to truly step back and

see what works and what doesn't, and to be quick in writing formulas

and making a diagnosis. But of course I feel I have many more years of

knowledge and experience to gain. So in no way would I step up to a

plate and call myself any kind of master. LOL

So in my practice I too believe it is essential to keep it simple.

Since my true love is to focus on dermatological conditions (I do also

treat many other conditions), I will talk about the way I diagnose them.

First off I believe it is obviously very important to know the

condition that you are faced with very well. To know by heart the

main, most common patterns that a given " disease " can manifest with.

This way one can easily stick to the point and not waist time thinking

about patterns that are not that common or do not make much sense.

For instance, in the diagnosis and treatment of psoriasis I look for a

few main manifestations that have very characteristic appearances. I

know that almost all psoriasis patterns are going to involve some

element of blood heat and fire toxin, in obvious varying degrees. I

can then look for the other common add on tendancies, like wind, blood

stasis, damp heat, Qi level heat, etc. I know that yin xu is usually a

common problem, but in practice it seems to be best to clear out the

pathogenic heat from the various levels before focusing on nourishing

the yin. From my practice and that of my teachers, the end result is

success.

So when I see a psoriasis patient with very dry, tethered and static

lesions that they have had for years. The lesions have lots of scale

that is slightly brown and with an active auspitz sign and no itch. I

will start by aggressively clearing out blood heat, resolving fire

toxin, and gently invigorating the blood. If the lesions are

unresponsive to treatment then I up the fire toxin resolvers and even

the blood invigoraters, even go to the breaking blood category. Then

when the lesions are finally resolved and the skin that is left is dry

and hyperpigmented, then my treatment will involve nourishing yin and

invigorating blood. Ie. the dx and treatment changes as the lesions

change and heal.

Even in atopic eczema. Blood xu can be a very important element, to

truly treat it well, I find the pathogenic heat and or dampness has to

be dealt with first. I rarely use dang gui in the initial

prescription, as it is too warm. But in the finally remission stages,

dang gui is an excellent herb.

Anyways I am rambling on here. Basically, keep it simple. By simple I

mean- know the conditions that one is faced with really well. Know

what their main and MOST COMMON patterns of presentation are. And then

write the formula from there.

My 10 cents

Trevor

, " "

wrote:

>

> Doug,

>

> My off the cuff answer: The diagnosis is what you see as the problem

that

> you have to deal with at that moment in time to eliminate the

symptoms or to

> allow you to get to the next layer. One person may name 6 patterns and

> another just something a simple as " shaoyang - yangming " . Qin Bo-Wei

> actually talks specifically about this. I don't have my Chinese books in

> front of me, but he basically says, many people see patients and

think they

> are complex and don't fit any of the standard patterns and formulas.

He says

> this is only because they don't have a clear methodology.

>

> The diagnosis should relate directly to your treatment principles

and this

> should directly relate to you choice of treatment. For example if you

> diagnosis yin xu and do not treat it, then this makes little sense

to me.

> Therefore I do not think a diagnosis is the place to mention mere

> observations that we see that are happening (unless directly

treated). This

> is best reserved for pathomechanisms and discussion.

>

> Furthermore, there are some times where the deepest and root problem

is not

> addresses right away, therefore naming it as the diagnosis seems

illogical.

> If one has a straightforward wind attack which is simple addressed by

> 'diffusing the Lungs and dispersing wind' then it also makes little

sense

> into diagnosing there underlying patterns.

>

> However, amny times root patterns are essential to acute or branch

> treatments. For example, if you have an underlying Liver Yang rising and

> have an external attack, it is completely reasonable to diagnosis

Liver yang

> rising with a wind pathogen on the exterior. Underlying patterns often

> affect how we treat acute situations.

>

> I think the biggest issue is, when people name multiple diagnoses it

is not

> from a complex patient, it is from the inability to understand

> pathomechanisms. Meaning, if one believes that nocturia always comes

from

> Kidney deficiency or if one sees dry mouth, dry skin, and night

sweats and

> concludes there MUST be yin deficiency without taking into

consideration the

> whole picture then there may be unnecessary diagnosis.

>

> I think we all agree that this is the major issue.

>

> The clearer my theory has become the clearer I see patients and the

simpler

> I treat, but that is just me.

>

> Doug (and others) what is your opinion on what diagnosis means to you?

>

> -

>

> _____

>

> On Behalf Of Douglas

> Thursday, August 14, 2008 9:14 PM

>

> Re: Pattern Identification

>

> So the question is " what is a diagnosis " ? Of the root, of a pattern of

> dysfunction... Should we include a base diagnosis and a branch

> diagnosis? Is a diagnosis simply an observation of " something

> happening " or is it always the (main) road to treatment?

>

> Doug

>

August 16, 2008

Jason

I said they had the reputation of getting great results, ie explaining

their popularity. SInce i have not verified it as far as i am

concerned at the time, 1985, it could also mean patient thought they

got a better deal because they got lots of herbs for the same price.

When i speak about results i only speak of the cases i was able to

follow in detail. For me to evaluate result i need to know what we

treat since too many conditions resolve on their own among other

factors.

400 29th St. Suite 419

Oakland Ca 94609

alonmarcus

August 16, 2008

I'm a fairly new practitioner and I also get overwhelmed by complex

patients that have many patterns (5+). I've found it helps to try and

concentrate on how the patterns interrelate before writing a formula.

This helps me to see the patient as a living whole, rather than as a

list of patterns. Usually I find that patients can be reduced to a

couple of pattern-complexes that are each made up of 2 or more

individual patterns. When I can see the inter-relationships between

the patterns, I can look for formulas, dui-yaos, and individual herbs

that overlap with these inter-relationships. When I read case

histories or analyze other doctor's formulas it's this kind of deeper

insight that really teaches me things, as opposed to cases where the

doctor seems to be only giving a couple of herbs for each pattern

present.

Great topic, I appreciate the other insights people have posted.

August 16, 2008

I agree with you Carl,

I think that the cause for beginners coming up with overly complex diagnosis

(and formulas) is the lack of distilling as many symptoms down to as few

causes possible. Let me demonstrate. Let's say a patient presents with the

following:

- frequent urination

- aggravated by stress

- cold hands and feet

The beginner will describe this as one syndrome per symptom. So, they might

say that this patient has

- Kidney qi deficiency,

- Liver qi stagnation,

- Kidney yang deficiency.

However, Liver qi stagnation can actually explain ALL of these symptoms and

(lacking further signs and symptoms) I would lean toward the Liver qi

stagnation in this patient.

The goal in my mind is to see how few syndromes can explain the

constellation of signs and symptoms that a patient presents with. This is

not a skill that is easily obtained while you're busy memorizing data in

school. But it is a skill that comes in very handy in practice.

The goal is to find as few causes for all indications as possible. The most

simple explanation is probably the best.

-al.

On Sat, Aug 16, 2008 at 9:49 AM, carlstimson <carlstimson wrote:

> I'm a fairly new practitioner and I also get overwhelmed by complex

> patients that have many patterns (5+). I've found it helps to try and

> concentrate on how the patterns interrelate before writing a formula.

> This helps me to see the patient as a living whole, rather than as a

> list of patterns. Usually I find that patients can be reduced to a

> couple of pattern-complexes that are each made up of 2 or more

> individual patterns. When I can see the inter-relationships between

> the patterns, I can look for formulas, dui-yaos, and individual herbs

> that overlap with these inter-relationships. When I read case

> histories or analyze other doctor's formulas it's this kind of deeper

> insight that really teaches me things, as opposed to cases where the

> doctor seems to be only giving a couple of herbs for each pattern

> present.

>

> Great topic, I appreciate the other insights people have posted.

>

--

, DAOM

Pain is inevitable, suffering is optional.

August 17, 2008

Since every patient is an experiment between theory and therapy, if

you want to hone your skills its always better to treat with as simple

a formula as you can. The problem is often the time frame you have to

work with each patient. Sometime we use a more complex formula because

we are not sure what is key for a patient and are not allowed the time

to explore using simple formulas. While it may work clinically we

really cannot learn from these. I wander if Bob want to chime in since

he feels that one must treat all the patterns at the same time to get

sustaining results.

400 29th St. Suite 419

Oakland Ca 94609

alonmarcus

August 19, 2008

, " Alon Marcus "

<alonmarcus wrote:

>They were looked down upon by most of the other Dr because they never

attended school. They were not even made to take the courses that most

other older dr had to take, ie western med for the most part.

Are these the 'farmer scholars' from the great leap forward? Some are

in our schools teaching today as well. To me - it doesn't matter much

since they still have more experience and training than many of us

will, but the resentment is understandable considering modern history.

Anyways - I think something to help 'tie-break' the patient's pattern

is to treat the main complaint. If you treat something the patient

didn't come to you for, you're not likely to have a happy patient.

Geoff

August 19, 2008

Alon and members,

As Alon stated- every patient is an experiment between theory and

therapy. I find this to be very helpful to remember. I am continually

faced with the following problem regarding CM theory:

If you are resourceful enough and consult enough texts or

practitioners, you can pretty much find a match b/w any symptom and a

pattern. Because of the inter-relatedness of CM physiology and

patterns, there always seems a way to make connections. This is what I

believe is the hardest for students and new practitioners.

Al's cases are prime examples: bound constipation narrowed down to yin

or blood vacuity (what about the LU not descending, or the SP not

making fluids), or the three sign of cold/hands feet, stress, and ?,

narrowed to down to LV constraint.

CM diagnosis is so subjective and I think many just fall into

comfortable ways of doing it through time. But as a 2 year old

practitioner, who is still very interested in the medicine and

improving clinical results, this is my biggest issue.

Any words of wisdom?

Dave Vitello

, alon marcus

<alonmarcus wrote:

>

> Since every patient is an experiment between theory and therapy, if

> you want to hone your skills its always better to treat with as simple

> a formula as you can. The problem is often the time frame you have to

> work with each patient. Sometime we use a more complex formula because

> we are not sure what is key for a patient and are not allowed the time

> to explore using simple formulas. While it may work clinically we

> really cannot learn from these. I wander if Bob want to chime in since

> he feels that one must treat all the patterns at the same time to get

> sustaining results.

>

> 400 29th St. Suite 419

> Oakland Ca 94609

>

> alonmarcus

>

August 19, 2008

Geoff

'farmer scholars' not sure what you mean. These were older Dr

mostly from a family tradition with history in the community

400 29th St. Suite 419

Oakland Ca 94609

alonmarcus

August 19, 2008

Dave,

I think that it is a mistake to believe that there can be a match between

any pattern and symptom. Meaning, I do not agree that any symptom can be

caused by anything. I think this type of thinking leads to sloppy diagnosis

and we see this in students who just start making up theory and

pathomechanisms to explain symptoms. I do believe there is somewhat correct

and incorrect theory.

Granted there are such symptoms and patterns that do manifest with a wider

range of possibilities, there are others that are much more limited. This is

even especially true when one looks at the whole picture. That is to say,

when one starts to see all the symptoms together there really are only a

couple of possibilities. This is the essence of CM and Chinese thought.

Chinese think of things as interrelationships not individual signs and

symptoms. Hence all must be taken in context, and hence the possibilities

are not as broad as one might think. One idea is that Westerns, more so

than Chinese, see more individual signs and symptoms and miss the

relationships and hence come up with more patterns.

I think there is this unfortunate belief in the CM community (especially in

the schools) that if one takes 10 practitioners one can get 10 completely

different (yet correct) diagnoses. I completely disagree. Do we really

believe that if we gave that given patient those 10 different formuals that

they all would work equally well? There are usually more correct ones than

others.

I think this comes about because, in the West, we have quite a bit of

unorthodox thinking and strange systems of theory that do not necessary jive

with mainstream CM thought. For better or worse this leaves students with a

confusing dilemma. Who do I believe? This many times translates into the

conclusion that anything goes and CM is just a web of confusion and one can

justify anything by spinning some explanatory web of theory. In my humble

opinion, I think this is an incorrect conclusion. We should strive for

concrete and clear thinking that CM is built on. It is a very logical system

of thought that is fairly well mapped out.

Of course, there are many systems of thought in medicine and one cannot

discount varying approaches. But separating such systems from more standard

CM is useful so as not to come to the above conclusions. Furthermore, there

will always be exceptions and varying ways to approach problems (within CM),

but generally speaking there should not be as much disagreement and

confusion that is so present in the West.

What do others think?

-

_____

On Behalf Of dmvitello01

Tuesday, August 19, 2008 11:01 AM