Repeatability of TCM Dx between expert TCM practitioners

[Guest guest]

Hi Lea & All,

 

> Does anybody know anything about how much of a consensus there is

> among practitioners for a TCM diagnosis alone?

 

Lea, IMO you have fingered a significant problem in doing RCTs based

on TCM Dx.

 

In theory, if an expert TCM practitioner takes a careful history and does

a complete TCM diagnostic workup, including tongue and pulse Dx, the

Dx of the patients root & branch imbalances should be relatively

clearcut.

 

However, I suspect that if 10 expert TCM practitioners were presented

with the same set of patients with complex problems, their TCM

diagnoses for each patient would show much variation.

 

Can anyone cite publications which examined practitioner-to-practitioner

variation in TCM Dx for the same patient set examined?

 

Best regards,

 

[Guest guest]

I can't give you info about Dx consistency between

practitioners, however I did my major paper at TCM

school on interviewing and integrating data

representative of treatment techniques utilized by all

20 master practitioners on staff. This depended on

hypothetical conditions/dx/tx plan.

 

The results showed that the treatments varied

considerably from practitioner to practitioner for the

same condition - with only ONE technique consistent in

all practitioners.

 

The one consistent technique among master

practitioners at this college was applying the

treatment with INTENTION.

 

That was a very valuable study.

 

Regards,

 

Janis Egan

--- < wrote:

 

> Hi Lea & All,

>

> > Does anybody know anything about how much of a

> consensus there is

> > among practitioners for a TCM diagnosis alone?

>

> Lea, IMO you have fingered a significant problem in

> doing RCTs based

> on TCM Dx.

>

> In theory, if an expert TCM practitioner takes a

> careful history and does

> a complete TCM diagnostic workup, including tongue

> and pulse Dx, the

> Dx of the patients root & branch imbalances should

> be relatively

> clearcut.

>

> However, I suspect that if 10 expert TCM

> practitioners were presented

> with the same set of patients with complex problems,

> their TCM

> diagnoses for each patient would show much

> variation.

>

> Can anyone cite publications which examined

> practitioner-to-practitioner

> variation in TCM Dx for the same patient set

> examined?

>

> Best regards,

>

>

>

>

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[Guest guest]

On Tuesday 26 September 2006 16:07, wrote:

> Hi Lea & All,

>

> > Does anybody know anything about how much of a consensus there is

> > among practitioners for a TCM diagnosis alone?

>

> Lea, IMO you have fingered a significant problem in doing RCTs based

> on TCM Dx.

>

> In theory, if an expert TCM practitioner takes a careful history and does

> a complete TCM diagnostic workup, including tongue and pulse Dx, the

> Dx of the patients root & branch imbalances should be relatively

> clearcut.

 

Hi Dr. Phil!

 

Suppose the interface to the data allowed filtering out cases where the

posting physician did or did not do one or the other part of the examination?

Would that help?

 

Been working on this for eleven years now. Oh, well, what if it does take the

rest of my life . . .

 

Regards,

 

Pete

[Guest guest]

Hi Pete, & All,

 

Pete Theisen wrote:

> Suppose the interface to the data allowed filtering out cases where

> the posting physician did or did not do one or the other part of the

> examination? Would that help? Been working on this for eleven years

> now. Oh, well, what if it does take the rest of my life . . . Regards,

> Pete

 

Pete, please stick with your project! It took me 11 years (BEFORE the

advent of PCs) to develop my database that produced " Acupuncture

Formulas: Top Ten Points for Common Conditions " :

http://homepage.eircom.net/~progers/ff.htm

 

In comparison to YOUR project, mine was child's play. Yours, in

contrast, is far more complex. I wish you great success with it and

would value greatly a Beta Version!

 

IMO digital data storage, retrieval and pattern matching will be of great

value in all aspects of medicine, including TCM Dx and the selection of

appropriate remedies and dosages for the selected Dx.

 

I agree 100% that computers are ideal for a matching complex patterns

of input. A really good database that had all the signs and symptoms

logged for all the documented TCM Patterns, and an interface to

prompt input for missed examinations, should be able to make

consistent Dxs for complex patterns of input.

 

Therefore, TCM practitioners using THAT database should be able to

make pretty consistent Dxs.

 

HOWEVER, the problem is that practitioners who do NOT use THAT

database, or who use databases developed by other workers/groups,

may come up with different Dxs for the SAME set of inoutted S & Ss.

 

Unfortunately, computers do as they are told. They also obey the GIGO

Law - Garbage in = Garbage Out.

 

So the data stored in the database(s) dictates the matches that will

emerge when complex data are inputted.

 

Best regards,

 

[Guest guest]

Chinese Medicine , " "

< wrote:

>

> Hi Lea & All,

>

> > Does anybody know anything about how much of a consensus there is

> > among practitioners for a TCM diagnosis alone?

>

>Journal of Alternative and Complementary Medicine

Variability in the Traditional (TCM) Diagnoses and

Herbal Prescriptions Provided by Three TCM Practitioners for 40

Patients with Rheumatoid Arthritis

Jun 2005, Vol. 11, No. 3: 415-421

 

Objective: To ascertain if previous findings of low levels of

agreement of Traditional (TCM) pattern diagnoses made

by TCM practitioners in patients with rheumatoid arthritis (RA) were a

function of practitioner differences or would be replicated with a

different sample of clinicians, and to examine the relationship

between TCM diagnosis and herbal treatment plans.

 

Design: A prospective survey.

 

Setting: General clinical research center, University of Maryland

Hospital System, Baltimore, MD.

 

Subjects: Forty (40) patients with RA.

 

Practitioners: Licensed acupuncturists with at least 5 years'

experience and education in Chinese herbs.

 

Methods: Three (3) TCM practitioners examined the same 40 RA patients

separately, following the traditional Four Diagnostic Methods.

Patients filled out questionnaires and physical examinations,

including observations of the tongue and palpation of radial pulse,

were conducted by the 3 practitioners. Each practitioner then provided

both a TCM diagnosis and an herbal prescription. These

diagnoses/prescriptions were examined with respect to the rate of

agreement among the 3 practitioners.

 

Results: The average agreement with respect to the TCM diagnoses among

the 3 TCM practitioners was 31.7 % (range, 27.5–35%). The degree to

which the herbal prescriptions agreed with textbook recommended

practice for each TCM diagnosis was 91.7% (range, 85–100%). The most

commonly used TCM assessments in arriving at these diagnoses were

inquiry about factors affecting pain and pulse diagnosis. No

statistically significant differences were found between this study

and our previous study regarding the level of agreement on TCM diagnosis.

 

Conclusion: The average agreement of the diagnoses provided by 3 TCM

practitioners was at the same low level as previously reported. No

association was found between the diagnostic methods used and the

consistency of diagnosis. Both studies, however, found a high degree

of consistency between the TCM pattern diagnoses provided and the

herbal treatment plans made as a result of those diagnoses.

 

Grant G. Zhang, Ph.D. L.Ac.

Center for Integrative Medicine and School of Medicine, University of

Maryland, Baltimore, MD.

Wenlin Lee, Ph.D.

Center for Integrative Medicine and School of Medicine, University of

Maryland, Baltimore, MD.

Barker Bausell, Ph.D.

Center for Integrative Medicine and School of Medicine, University of

Maryland, Baltimore, MD.

Lixing Lao, Ph.D.

Center for Integrative Medicine and School of Medicine, University of

Maryland, Baltimore, MD.

Barry Handwerger, M.D.

Division of Rheumatology and Clinical Immunology, School of Medicine,

University of Maryland, Baltimore, MD.

Brian Berman, M.D.

Center for Integrative Medicine and School of Medicine, University of

Maryland, Baltimore, MD.

[Guest guest]

Chinese Medicine , " skip8080 "

<skip8080 wrote:

>

> >

> >Journal of Alternative and Complementary Medicine

> Variability in the Traditional (TCM) Diagnoses and

> Herbal Prescriptions Provided by Three TCM Practitioners for 40

> Patients with Rheumatoid Arthritis

> Jun 2005, Vol. 11, No. 3: 415-421

>

Thanks everyone,

Thats really interesting. The above findings are not necessarily what I

expected! I expected a higher consensus on the diagnosis and widely

differing herbal tx. Hmmm...food for thought.

Now for another annoying question, how much of a consensus is there

amongst western med. practitioners? To my mind this is a more

difficult question in one sense, because one major difference between

WM and TCM methodology is that in WM you can begin treatment in

the absence of a definitive diagnosis, which you cannot do in TCM.

(However you can always arrive at a TCM diagnosis, WM diagnoses

can be trickier, and some WM diagnoses are a diagnosis of exclusion.

i.e. We know what it isnt...)

How many practitioners and cases would you need to have a

statistically significant result re: Diagnostic variability?

If you tested this on paper. (Eg Reading a case history) would this

artificially increase consensus? Eg. because of practitioners not being

able to interpret subjective data such as pulse for themselves. Would

this still be useful?

If better minds than I have been struggling with this for 11 years,

perhaps Id better shut up now....

Regards,

Lea.

[Guest guest]

Hi All, & Skip8080:

 

I asked: >> Does anybody know anything about how much of a

consensus there is among practitioners for a TCM diagnosis alone?

 

Skip8080 rep;ied:

> Journal of Alternative and Complementary Medicine. Variability in the

Traditional (TCM) Diagnoses and Herbal Prescriptions Provided

by Three TCM Practitioners for 40 Patients with Rheumatoid Arthritis > Jun 2005,

Vol. 11, No. 3: 415-421

 

Many thanks.

 

http://www.medscape.com/viewarticle/508972 has an expanded

discussion of that article.

 

Best regards,

 

[Guest guest]

On Tuesday 26 September 2006 22:20, skip8080 wrote:

> Chinese Medicine , " "

<snip>

> Setting: General clinical research center, University of Maryland

> Hospital System, Baltimore, MD.

>

> Subjects: Forty (40) patients with RA.

 

Hi Skip!

 

One thing I intend to do with my application is NOT use acronyms. Is RA

Rheumatoid Arthritis, or something else?

 

Regards,

 

Pete

[Guest guest]

On Tuesday 26 September 2006 20:24, wrote:

<snip>

> > Suppose the interface to the data allowed filtering out cases where

> > the posting physician did or did not do one or the other part of the

> > examination? Would that help? Been working on this for eleven years

> > now. Oh, well, what if it does take the rest of my life . . .

>

> Pete, please stick with your project! It took me 11 years (BEFORE the

> advent of PCs) to develop my database that produced " Acupuncture

> Formulas: Top Ten Points for Common Conditions " :

> http://homepage.eircom.net/~progers/ff.htm

 

Hi Dr. Phil!

 

It will be a web application so every user will always have the latest

version. When the beta goes up everyone will be able to use it. I hope to be

able to let everyone contribute function on the fly as well. Anyone can

already contribute money via paypal, that part went up last week. Tax

deductable for US residents.

 

Regards,

 

Pete

http://sun-health.org/

[Guest guest]

On Wednesday 27 September 2006 02:10, Lea Starck wrote:

 

Hi Lea!

 

Provocative question, thanks for asking that. I would hope to have millions of

records soon after getting the application on line.

 

Consider how many English-speaking acupuncturists there are, and how many

patients they each see. Each patient visit to a participating physician

generates a record. If the system is affordable, helps establish the

knowledge base of the profession and speeds the individual practitioner's

paperwork - What's not to like?

 

The sticking point right now is paying for the programming I can't do myself.

The programmer has actually done quite a lot for free, but he has a family

and can't make a priority of something that doesn't pay.

 

To respond to your example, I want to define the pulse choices in the

interface (in sort of a " margin note " ) so we will all be on the same page.

 

Regards,

 

Pete

http://sun-health.org/

 

<snip>

 

> How many practitioners and cases would you need to have a

> statistically significant result re: Diagnostic variability?

> If you tested this on paper. (Eg Reading a case history) would this

> artificially increase consensus? Eg. because of practitioners not being

> able to interpret subjective data such as pulse for themselves. Would

> this still be useful?

[Guest guest]

Chinese Medicine , Pete Theisen

<petetheisen wrote:

>

 

>

> To respond to your example, I want to define the pulse choices in the

> interface (in sort of a " margin note " ) so we will all be on the same page.

>

>

Hi Pete,

Ive been reading some of the many threads on terminology, so good luck

to you there! (I was blissfully unaware of what a fraught issue it is until

subscribing to this forum.)

 

Regards,

Lea.

[Guest guest]

On Thursday 28 September 2006 21:04, Lea Starck wrote:

> Chinese Medicine , Pete Theisen

>

> <petetheisen wrote:

> > To respond to your example, I want to define the pulse choices in the

> > interface (in sort of a " margin note " ) so we will all be on the same

> > page.

>

> Hi Pete,

> Ive been reading some of the many threads on terminology, so good luck

> to you there! (I was blissfully unaware of what a fraught issue it is until

> subscribing to this forum.)

 

Hi Lea!

 

I have a little description of some of the pulses on my paper examination

sheet as it is, have a little look:

 

Floating pulse. Yes or no. (weak, deficient yin; strong, interior wind)

Sinking pulse. Yes or No. (yin, internal disharmony or obstruction)

Slow pulse less than 70 beats per minute. Yes or No. (cold or insufficient qi)

Rapid pulse more than 87.5 beats per minute. Yes or No. (heat is accelerating

the movement of blood)

Thin pulse feels like a fine thread but very distinct and clear. Yes or No.

(blood deficiency, often qi deficiency as well)

Big pulse broad and very distinct. Yes or No. (heat in stomach, intestines)

Empty pulse big with no strength, felt at the superficial level. Yes or No.

(deficient qi and blood)

Full pulse big, strong, pounding hard against the fingers at all three levels.

Yes or No. (excess)

Slippery pulse extremely fluid " ballbearing covered with viscous fluid " . Yes

or No. ( yang within yin; pregnant, excess damp or mucus)

Choppy pulse uneven and rough, and sometimes irregular in strength and

fullness. Yes or No. (thin, deficient blood or jing; not thin, congealed

blood)

Wiry pulse, taut feeling; strong, rebounds at all levels, hits the fingers

evenly; no fluidity or wave. Yes or no. (stagnation in the body, usually

related to a disharmony that impairs the flowing and spreading functions of

the Liver and Gall Bladder)

Tight pulse strong and seems to bounce from side to side like a taut rope.Yes

or No. (Yang within Yin, Excess, Cold and Stagnation)

Short pulse, does not fill the spaces under the three fingers and is usually

felt in only one position. Yes or No. (often sign of deficient qi)

Long pulse is perceptible beyond the first and third positions. Yes or No. (if

tight and wiry, excess)

Knotted pulse, slow irregular pulse that skips beats irregularly. Yes or No.

(cold obstructing Qi, Blood; Deficient Qi, Blood or Jing. Often a sign of the

Heart not ruling the Blood properly, more interruptions in rhythm, more

severe the condition)

Hurried pulse is a rapid pulse that skips beats irregularly. Yes or No. (Heat

agitating the Qi and Blood)

Intermittent pulse usually skips more beats than the previous two pulses, but

does so in a regular pattern. Yes or No. (Serious Heart disharmony, or it can

signal exhaustion of all organs)

Moderate pulse is the healthy, perfectly balanced pulse ‑ normal in depth,

speed, strength and width. Yes or No. (very rare, not necessary for a clean

bill of health)

Flooding pulse surges with the strength of a big pulse to hit the fingers at

all three depths, but leaves the fingers with less strength, like a receding

wave. Yes or No. (Heat has injured the Fluids and Yin)

Minute pulse is extremely fine and soft, but lacks the clarity of the thin

pulse. It is barely perceptible and seems to disappear. Yes or No. (extreme

Deficiency)

Frail pulse is soft, weak and somewhat thin. It is usually felt at the deep

level. It is like an inverted empty pulse. Yes or No. (extreme Deficient Qi

condition)

Soggy pulse is a combination of the thin, empty and floating pulses. It is

extremely soft, less clear than a thin pulse and is perceptible only in the

superficial position. Yes or No. (Deficient Blood or Jing, and sometimes of

Dampness)

Leather pulse is a combination of the wiry and the floating pulses, with

aspects of the empty pulse. It feels like the tight skin on the top of a

drum. Yes or No. (Deficient Blood or Jing)

Hidden pulse is an extreme form of the sinking pulse. Yes or No. (Deficient

Yang if weak. If strong, Deficient Cold obstructing the meridians)

Moving pulse is a combination of the short, tight, slippery and rapid pulses

felt in only one position, incomplete without a head or a tail. Yes or No.

(extreme condition rarely seen, cases of heart palpitation, intense fright,

fever or pain)

Hollow pulse, like the stem of a green onion, solid on the outside but

completely empty, often a floating pulse. Yes or No. (Deficient Blood, often

seen after great loss of Blood)

Scattered pulse, similar to empty pulse, floating, big and weak; larger and

much less distinct than empty pulse, however tends to be felt primarily as it

recedes. Yes or No. (serious Disharmony ‑ Kidney Yang is exhausted and is

floating away)

Radial pulse: Left distal (first) Heart; Left central (second) Liver; Left

proximal (third) Kidney Yin; Right distal (first) Lungs; Right central

(second) Spleen; Right proximal (third) Kidney Yang, Mingmen, Life Gate Fire.

 

Where this is wrong or incomplete please give me the correct information.

Thanks.

 

Regards,

 

Pete

http://www.pete-theisen.com/

>

> Regards,

> Lea.

[Guest guest]

Hi there,

I dont really have a problem with any of those, but then Im not a big

terminology afficianado. (You say potato, I say spud.) Although how would

you factor in pulses that have a certain characteristic in a given position?

(Slippery in the chi3 position? Superficial in the lung position?)

 

Just out of interest, I was told the following pulse:

> Hollow pulse, like the stem of a green onion, solid on the outside but

> completely empty, often a floating pulse. Yes or No. (Deficient Blood,

often > seen after great loss of Blood)

 

would only be seen in the few minutes before a patient " bled out " in

serious trauma. (The teacher who taught us pulse had been an emergency

medicine specialist in China.) So I was told that it would be fairly rare to

feel that one in everyday practice. (One would hope!)

 

Regards,

Lea.

[Guest guest]

On Saturday 30 September 2006 04:08, Lea Starck wrote: <snip>

> how would you factor in pulses that have a certain characteristic in a given

> position? (Slippery in the chi3 position? Superficial in the lung

> position?)

 

Hi Lea!

 

I am waiting for someone to contribute that <s>. I am busy working on the

money/practice management module right now because that is what I am hearing

that people want.

 

Thanks for the tidbit about hollow pulse!

 

Regards,

 

Pete

> Just out of interest, I was told the following pulse:

> > Hollow pulse, like the stem of a green onion, solid on the outside but

> > completely empty, often a floating pulse. Yes or No. (Deficient Blood,

> often seen after great loss of Blood) would only be seen in the few minutes

before a patient " bled out " in serious trauma. (The teacher who taught us

pulse had been an emergency medicine specialist in China.) So I was told that

it would be fairly rare to feel that one in everyday practice. (One would

hope!)