Title: From theory to clinic: key components of qi deficiency in traditional Chinese medicineKey Constituents of Qi Deficiency in Traditional Chinese Medicine
Running title: Key Constituents of Qi Deficiency Authors (in publishing order)
Chiang Hui-Chu, RN, MSN.
Lecturer, Department of Nursing, Chang Gung Institute of Technology, Taiwan PhD student, Institute of Medicine, Tzu Chi University, Taiwan
Su-Tso Yang M.D. Ph.D
• School of Chinese Medicine, China Medical University and Department of Radiology, China Medical University Hospital
Chang Hen-Hong, M.D., Ph.D.
Vice-superintendent, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital
Professor, Graduate Institute of Traditional Chinese Medicine, Chang Gung University
President, Formosa Association of Clinical Diagnosis in Traditional Chinese Medicine, Taiwan
Lee Ko-Chen, M.D., M Med.
Lecturer, School of TCM, Chang Gung University, Taiwan Huang Po-Yu , M.D., M Med.
Department of traditional Chinese medicine, Taipei city hospital, Linsen branch, Taiwan
Hsu Mu-Tsu, Ph.D.
Dean, College of Humanities and Social Sciences, Tzu Chi University, Taiwan Su-Tso Yang M.D. Ph.D
• School of Chinese Medicine, China Medical University and Department of Radiology, China Medical University Hospital
Chang Hen-Hong, M.D., Ph.D.
Vice-superintendent, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital
Professor, Graduate Institute of Traditional Chinese Medicine, Chang Gung University
President, Formosa Association of Clinical Diagnosis in Traditional Chinese Medicine, Taiwan
Correspondent Authors Hsu Mu-Tsu, Ph.D.
Dean, College of Humanities and Social Sciences, Tzu Chi University, Taiwan Chang Hen-Hong, M.D., Ph.D., Professor
Chang Gung University
Graduate Institute of Traditional Chinese Medicine E-mail: [email protected];[email protected]
TEL: 886-3-2118866 Ext. 3470 Fax: 886-3-2118866 [?]
Kwei-Shan, Tao-Yuan, Taiwan, 33333 Chiang Hui-Chu, RN, MSN, lecturer
Chang Gung Institute of Technology Department of Nursing
E-mail: [email protected] [email protected] TEL: 886-3-2118999 Ext. 3108
Fax：886-3-2118866
Address: 261 Wen-Hwa 1st Road
Kwei-Shan, Tao-Yuan, Taiwan, 33333 Institution(s) in which the work was performed
Grants: This study was supported by CCMP95-TP-039, Committee on Chinese Medicine and Pharmacy, Taiwan Department of Health.
From theory to clinic: key components of qi deficiency in traditional Chinese medicineKey Constituents of Qi Deficiency in Traditional Chinese Medicine
ABSTRACT Objective:
Making correct diagnoses is the foundation of clinical practice in Traditional Chinese Medicine (TCM). However, it has been well recognized that the diversity in making diagnoses is one of the leading handicaps for the proper use of TCM. The purpose of this study is to investigate what are the key constituents used to diagnose qi deficiency among the TCM experts.
Methods/Design/ Participants:
Three approaches were used to identify the proposed key components for the diagnosis of qi deficiency in TCM, by:browsing throughstudying primary research results,
government-defined diagnostic guidelines, and journal articles. Symptoms, signs, and risk factors were then extracted for questionnaire formulation. A modified Delphi process was used to gain consensus from TCM experts. A five-round postal questionnaire was carried out over two years. Open-ended questions were used to ask about uncovered issues. The higher the selection rates for each item, the greater the degree of agreement of the experts. Content analysis of the qualitative data was carried out at each stage. Additional statements about diagnosing qi deficiency were compiled from the preceding
questionnaire. New components were generated, and statements selected by a minor portionsmall proportion of experts were excluded during the modified Delphi process. In the final round, only statements chosen by more or equal to 70% of the panelists or more,
and those also showing a tendency of convergence, were retained. Results:
Twenty-eight of the total of thirty 30 experts, consisting of scholars, researchers, and experienced clinicians, completed all five surveys. Seventy-four symptoms and signs and thirty-nine risk factors were initially identified as the preliminary elements in the
diagnosis of qi deficiency in the first questionnaire. After a five-round postal survey, the final content included two definitions, 19 symptoms and signs, and 15 risk factors as the key constituents of qi deficiency in TCM.
Conclusions:
The Delphi technique enabled TCM experts to work with others and proved a practical method for reaching consensus about clinical assessment issues relevant for qi deficiency. The results show that for diagnostic purposes, TCM doctors use a set of more complex methods to diagnose rather than just simple comparison of enacted disease
characteristics.
Introduction
Considering the recent rapid increase in the worldwide use of Traditional Chinese Medicine (TCM), there is an urgent need for the appropriate use of traditional medicine. In this context, the WHO Regional Office for the Western Pacific has been promoting “standardization with evidence-based approaches”, such as that on in areas such as
terminology, acupuncture point locations, and herbal medicine.1 Efforts have been made
by using a range of approaches, including the standardization of TCM terms,2 the
utilization of mechanical devices to detect human bioenergy3, and the development of
diagnostic questionnaires for Cold-Heat patternization, Yin-deficiency,4 posttraumatic
stress disorder,5 and intestinal Behçet’’s disease;6 and the assessment and improvement of the consistency in diagnosis among practitioners.7-9 Few validated instruments have been
announced in for making diagnosis objectively.4, 10-11
In TCM, health is conceived as a balanced state among qi, blood, yin, and yang. Disease is supposed to appear when these four elements lose fall out of balance. “Qi deficiency” is one of the most familiar disease patterns in TCM. The Government of
mainland the People’s Republic of China (PRC) promulgated two guidelines of regarding
qi deficiency patterns for clinical practice in 1986 and 2002.12-13 In those diagnostic
guidelines, qi deficiency is regarded as a manifestations of correlated symptoms and signs (S/S). The task of TCM practitioners in diagnosing qi deficiency is therefore to compare the patients’’ symptoms and signs with enacted index, and then, to decide a course of treatment. The agreement among TCM practitioners is a major issue to be discussed7-8,
but still, the published guidelines as mentioned above are currently used as the diagnostic standards in clinical researches regarding qi deficiency.14-15 On the other hand, some
researchers carried out literature review to define diagnostic criteria of qi deficiency.16-17
However, the defined diagnostic indicators remain different.
This disagreement among different experts has resulted in different interpretations of qi deficiency.18-19 In other words, whoever asks if you ask for help from TCM doctors is you are more likely to be at risk of the diversity of differing judgments. Therefore, it is necessary to choose from the differing clinical diagnostic perspectives, to clearly understand various descriptions of clinical manifestation, and to decide which criteria should be met in a clinical decision as to whether a patient has qi deficiency or not. The aims of this study are to investigate whether any consensus regarding qi deficiency can be reached among the TCM experts and what are the key constituents used to diagnose qi deficiency.
Methodology
The Delphi technique is a continuous, systematic method for collecting and
extracting knowledge from a group of experts via two or more rounds of questionnaires. The strengths of this technique include overcoming some biases that may arise from group personality, interpersonal dynamics, and dominance by key opinion leaders, prioritizing information provided by experts, minimizing differences in opinion, and so drawing opinion together toward a consensus.20-23 Modified Delphi methods have been
used in various areas of medicine to develop consensus when clinical evidence is lacking and relies mostly on expert opinion, and to develop guidelines and evidence-based
practice.
Accordingly, in the absence of agreement on the diagnosis of qi deficiency, clinical practice usually depends on practitioners’’ own experience. We employed a modified Delphi technique to gather opinions from TCM experts and to identify the key
constituents of qi deficiency diagnosis.
The Delphi experts/ Panelists
Success of the consensus process relied on panelists’’ willingness to persist. Experts with excellent knowledge and practical ability are the ones who can afford provide
practical and concrete comments. Major TCM institutions in the PRC and Taiwan were asked to provide suggest professional candidates of in TCM diagnosis. Through this process, a list of 53 experts was produced. The qualifications of the panelists are shown in Table 1.
Face- to- face or phone- call invitations were used to invite participation and to explain the purpose of this study, as well as what contribution would be involved. Thirty experts (57.69%) agreed to participate. They were composed of diagnostic professors, TCM theoretical experts, and specialists of in TCM formulae and pharmacies. Thirteen participants were from the PRC, and seventeen 17 from Taiwan, including esteemed scholars, researchers, and experienced clinicians. All of the panel members have worked as clinical doctors; each of them has more than one specialty. The average length of clinical experience was 24.41 11.89 (2SD) years (range 4.5–44). The average years of experience on in teaching TCM was 18.16 13.03 (2SD) years (range 0–44) (Table 2).
Methods: the Delphi process
A five-round postal survey was carried out in over two years, generating both qualitative and quantitative data. The experts were asked to assess whether or not statements were related to the diagnosis of qi deficiency. Descriptive statistics for each item in the questionnaires were calculated. The higher the selection rates for each item, the greater the degree of agreement of the experts. Mean and standard deviation were used to indicate the degree of experts’’ agreement and disparity in the panel for each item. Content analysis of the qualitative data was carried out at each stage. The new ideas generated from each questionnaire were incorporated into the following questionnaire as feedback for the panel. The cover page of the subsequent survey explained the partial revisions of the questionnaire content and indicated how to administer the questionnaire. We hoped that use of the above method would enable the experts to offer revised
opinions after reconsideration of the appropriateness of each statement. The process model is shown in Table 3.
Qi deficiency Questionnaire I (Qi-dQ1), consisting of 74 statements of possible symptoms and signs (S/S) and 39 statements of possible risk factors of qi deficiency, was developed from three sources. They included The Operational Procedure for Symptoms and Signs in Traditional Chinese Medicine2; two Government-defined specified
diagnostic guidelines from the PRC12-13; and journal articles from electronic databases
regarding qi deficiency, such as The Chinese Thesis Periodical (CNTP), Taiwan Electronic Periodical Services (TEPS), Index to Chinese Periodical Literature
(PerioPath), and PubMed.
Although risk factors were left out of consideration in the three guidelines
mentioned above, qi deficiency is mostly discussed in terms of possible etiologic factors and clinical manifestation in TCM textbooks and research reports. Hence, the first-round questionnaire (Qi-dQ1) in this study includes clinical characteristics of qi deficiency and its risk factors. Every item was converted into conversational language based on the results of previous researches.16-17, 24-25 The categories of S/S are as follows: daily
activities, discomfort affecting the whole body, respiration-related signs, way of
speaking, appearance of tongue, appearance of face, complaints of sweating, elimination of bodily waste, sensation related to cold and hot, appetite complaints, sensation related to heart- beat, and manifestation of pulse. For risk factors of in qi deficiency, the
questionnaire looked for demographic information, lifestyle, and illness history. No recognized definition of “qi deficiency” was presented, to remove all constraint on allow complete freedom of original thought. Open-ended questions were used to ask about uncovered issues. The questionnaire was pre-tested by five Taiwanese medical doctors, each with more than two years of clinical experience. It took them 15-60 minutes to fill out the Qi-dQ1.
Qi-dQ1 was submitted to the panelists. Other In addition to than reviewing the given statements based on their clinical experience, they were asked to freely express any opinions concerning qi deficiency through in the open-ended question parts. After clarification of obscure points through telephone calls and face-to-face confirmation, content analysis of the qualitative data was done. No effort was made to force experts to reach consensus. Only the same or similar statements were eliminated. All of the original wordings were retained to avoid prejudice and misapprehension misunderstandings from on the part of authors. An additional 104 statements for S/S and 21 statements for risk factors were developed. “Relevant, but not necessary” was added to the options of items, and a third issue, definition of qi deficiency, was extracted from the opinions and formed by four open-ended questions. Based on these qualitative data, the second questionnaire (Qi-dQ2) was further divided into three parts: (1) issues about S/S; (2) issues about risk factors; (3) issues pertaining to the definition of qi deficiency.
From rounds two to four, questionnaires were sent to the panelists for sequential assessment. The response from the preceding round was compiled into the proceeding next questionnaires. Statements were selected depending on the responses of the experts. The higher the selection rates for each item, the greater the degree of agreement of the experts. Statements selected by fewer than or equal to 30% or fewer of the experts were excluded, to narrow the list of issues in the third round. In the fourth round, symptoms and signs chosen by fewer than 70% of the experts were eliminated, while risk factors and definitions selected by fewer than 50% were excluded. And then, the final content with items chosen by more or equal to 70% or more of the panelists was delivered to the 28 experts for final confirmation in the fifth round.
RESULTS
Twenty-eight experts out of the thirty 30 panelists completed all of the five surveys. From the first, they provided their opinions enthusiastically in the open-ended questions. Qi-dQ1 included S/S and risk factors only. The definition of qi deficiency was mentioned
after Round 2. The final survey included two definitions, 19 S/S, and 15 risk factors as key constituents of qi deficiency in TCM (Figure 1). A description of the results follows.
Definition of qi deficiency
The definition of qi deficiency was discussed from roundRound 2 onward. Eight statements were generated by Qi-dQ2. However, consensus was reached after three more rounds of the survey (Table 4). Most of the panelists, 85.71%, agreed that the two
selected statements covered the core elements of qi deficiency definition based on their clinical experience: 1) qi deficiency is a series of manifestations of functional decline of in the whole body in clinical situations in TCM; and 2) qi deficiency for specific viscera is, in qi deficiency terms, hypofunction of those specific viscera. In other words, some expressions are universal for every pattern relevant to qi deficiency, and some are specific to certain viscera.
Core symptoms and signs
According toIn the responses in the first questionnaire, 104 new S/S were generated. These were incorporated into the results of the formal expert survey that was conducted later. Table 5 presents the development of S/S through four rounds of the Delphi process. Finally, only nineteen statements were retained, in which five statements were findings from inspection in clinical encounters, three was found by listening, ten were related to patients’’ complaints, and one was detected by palpation.
The five inspective statements involved facial and tongue appearances. There were two statements about observed facial appearance: exhausted and spiritless facial
expressions. The important tongue appearances were tender-soft tongue, pale tongue color, and fat tongue. The listening statements from observed verbal performance
included talking without strength, faint voice, and shortness of breath while talking. Only
forceless pulsation was the only one detected by palpation.
The complaints included four categories: daily activities, perspiration, respiration, and elimination of bodily waste. The complaints related to daily activities included: feeling fatigue, feeling fatigue after mild activities, feeling a lack of physical strength, feeling unable to lift one’s spirits, and feeling tired after meals. Sweating during mild activities and aversion to wind, and sweating during the daytime with no apparent cause were the two complaints relevant to perspiration. There were two complaints about respiration. Constant shortness of breath and lacking physical strength while breathing were included to addressamong respiratory problems. The only important symptom related to elimination of bodily waste was weak urination.
Risk factors of for qi deficiency
Risk factors in Qi-dQ1 included 39 statements in 3 three categories, and were expanded in the subsequent questionnaires. Finally, 15 risk factors were chosen by more than 70% of experts, along with a tendency of convergence (Table 6). Three of the risk factors were related to the lifestyle of patients, five to the illness history in childhood, and seven to the illness history in adulthood. The lifestyle-related factors were long-term inadequate food intake, standing and talking for a long time everyday, and hard labor despite self-knowing weakness or pain.The noteworthy illness histories in childhood were weakness and frequent sickness, frequently catching cold, long-lasting diarrhea,
frequent diarrhea, and proneness to catching cold. The important illness histories in adulthood were frequently catching cold, prolonged cold, chemotherapy, chronic disease, long-term hospitalization, a major surgical operation, medical malpractice, and
consumptive disease. All of the chosen risk factors focused on mainly involved the long-term effects of an an exhaustinged lifestyle.
DISCUSSION
As intended, the Delphi technique proved to be a practical method for gathering expert opinion and for reaching consensus on the numerous clinical issues relevant for qi deficiency. Several efforts were done initiatives were undertaken to assure the validity of the results. We intended Our aim was to create an opportunity for the Delphi group to discuss the concept of qi deficiency from different standpoints based on individual clinical experience, and experts with varying experience were invited to avoid bias in selection. Telephone calls made every two weeks from the first round were used to confirm receipt of documents and to emphasize on the importance and our appreciation of their engagement. Each round spanned about three months, due to the difficulty of
contacting the panelists with wide geographical distribution, busy traveling schedules, and lecturing commitments. Two experts dropped out because of their career changes in
roundRoundsfour 4 and five5.
The initial questionnaire (Qi-dQ1) only offered structured questions concerning the statements of possible S/S and risk factors of qi deficiency pattern, as suggested by previous studies and guidelines. However, it was difficult for TCM experts to achieve adequate expression of ideas by pen-and-paper methods alone in this study, because different wordings were used by the experts to describe similar symptoms and signs. We used telephone calls and face-to-face interviews to enable a more accurate expression of ideas retrieved from open-endeding questions.
In order to give the experts more freedom to express their entire full diagnostic consideration of qi deficiency, no recognized definition of qi deficiency was presented in Qi-dQ1. This triggered discourse among the experts. They enthusiastically expressed their opinions through questionnaires, interviewing, and telephone calls. This enthusiasm greatly expanded the number of statements relating to the definition of qi deficiency in the first and second rounds. At the same time, the main ambiguity came from numerous statements relating to clinical manifestation (S/S). It was interesting to note that most opinions obtained the agreement of less than one-third of the experts or were pointed out to be problematic by some panelists.
Eight definitions of qi deficiency were extracted from the returned Qi-dQ3
questionnaire. It seems that the different discourses of definition were based on experts’’
own understanding of the nature, production, transformation and distribution of qi. This understanding sprang from their own knowledge of fundamental TCM theories and direct clinical observation. On the cover page of each questionnaire, the panelists were
repeatedly reminded that only definitions relevant to clinical practice should be provided. In the end, the remaining two definitions are were all related to the functional decline of human body. Also in concordance, the 19 reserved retained S/S all indicated certain aspects of functional decline.
In the part of about S/S, the statement regarding fatigue after mild activities gained 100% of agreement in roundRoundthree3. As shown by the statement, when a person was in the a situation with involving holistic functional decline, even mild activities, such as having a meal or talking, would trigger the fatigue sensation. Tender-soft tongue is another statement that gained total agreement from the panelists. In TCM contexts, the term “tender-soft” carries a meaning of fresh pallor. If the qi deficiency pattern was is not corrected, this would will further induce blood deficiency, represented partly by paleness of the tongue. It is the same with observed facial appearance, : concomitant blood
deficiency pattern must also be ruled out when a colorless facial complexion without luster is visualized.
Some statements regarding S/S, such as sawtooth-like tongue margin, shortness of breath after mild activities, a colorless facial complexion without luster, and simultaneous constipation, weakness, and shortness of breath, gained more than 50% of agreement, but showed no convergence even after roundRound 3. This trend of divergence for the above-mentioned statements is present because many TCM disease patterns, such as dampness, yin deficiency, and yang deficiency, may intertwine clinically with qi deficiency, thus leading to the selection of dubious statements by many experts. Therefore since from roundRound 4, many panelists stressed the importance of differential diagnosis for the correct identification of qi deficiency patterns.
For the observed verbal performance, all three published TCM guidelines mentioned the sign of sluggish speech as a key component of qi deficiency patterns.2,12-13 Although it
was included in the first two questionnaires as “occasional verbal response after repeated questioning,”, this statement was deleted eventually because it was selected by less than 10% of the panelists in the first two rounds. Talking without strength, faint voice, and shortness of breath while talking gained the agreement of the experts instead.
For the complaints related to the perspiration, the panelists had chosen “sweating during mild activities and aversion to wind” and “sweating during the daytime with no apparent cause” as the towo representative statements with convergence. For patients with qi deficiency, easy perspiration and aversion to wind correlate well with the lack of surface protective energy due to holistic functional decline of the body in TCM theories.
One statement worthy of noteing is that “weak urination” (urinating without strength)
gained the agreement of most panelists (86.67% in roundRound 3) in this study. Previously, it was not often mentioned in the diagnostic criteria of qi deficiency. Some panelists thought weak urination is more easily found in the elderly and debilitated patients with kidney qi deficiency or kidney yang deficiency. But, the latter presentation frequently coexists with frequent urination and urinary impaction, while the former is linked to the mechanisms of “spleen failing in transportation” and “sunken middle qi” in qi deficiency patterns and can be accentuated by daily activities and accompanied by fatigue sensation.
Looking more closely at the consensus relating definition and clinical manifestation, qi deficiency expresses as a lack of strength to empower the whole body and is referred to widely varied dysfunctions for different parts of the body, which can frustrate daily activity, respiration, perspiration, elimination of bodily waste, verbal performance, tongue and facial appearance, and human pulsation. The panelists were aware of
diverging manifestations of qi deficiency in clinical encounters and raised differing concerns. This awareness stressed the importance that TCM doctors must clarify the likelihood of specific S/S in order to diagnose precisely.
In concordance with the demonstration of textbooks, all experts mentioned that the core components of TCM diagnosis should be obtained from all of the four examinations (inspection, listening and smelling, inquiry, and palpation). In our study, most of the nineteen S/S of qi deficiency can could be detected by inspection or through a patient’’s complaints, ; three signs could be judged by listening, and only one pulsation sign was
detected by palpation. This result is different from the efforts findings of recent research,es which hasve focused on finding a list of symptoms alone for specific diseases.4-6, 10, 16-17, 25-26
The mentioning of risk factors during the Delphi process is an unique and important component in this study. Previously published articles and diagnostic guidelines always left out risk factors, but discursive essays and textbooks usually pay more attention to them2, 12, 13. Based on the expanded statements and arguments of risk factors through the
Delphi process, such clauses are certainly important in qi deficiency diagnosis. After the third-round survey, the retained statements addressed the long-term effect of exhaustion due to lifestyle and illness factors. Among them, the common cold, occurringed during childhood or adulthood, is considered to be closely related to qi deficiency. Some experts argued that “frequently catching cold” and “proneness to catching cold” represented the same meaning and should not appear as different statements. But, according to most panelists, “frequently catching cold” refers to the frequency, while “proneness to catching cold” refers to the greater likelihood of means easy contraction of a cold when most of the surrounding population is unaffected. Regardless of whichIn either case, frequent or easy contraction of cold indicated the accumulation of external pathogenic injuries and subsequent functional decline of in the human body.
Many statements agreed on by a few experts were deleted since from the third-
round survey, although they might represent meaningful clinical implication and experience, and possible topics of future exploration. In addition, a lot of terms in from
modern medical termsine were mentioned as risk factors of for qi deficiency, such as pulmonary sclerosis, pulmonary fibrosis, chronic obstructive lung disease, hypotension, mitral valve relapse, post-surgery factors, long-term use of laxatives, diuretics,
antipyretics & and analgesics, and antibiotics. Although they gained the agreement of less than one-third of the experts, further investigation of the relationship between TCM patterns and the modern medical terms would be worthwhile. It may also open up new fields in which TCM can respond to the exhausted nature of certain diseases and aid in the treatments of modern medicine.
Conclusion
In this article, we describe the systematic development of consensus for key constituents of qi deficiency patterns in TCM. Our results are different from the efforts endeavors of other recent research,es which have has focused on finding a list of
symptoms alone. Our study categorized key constitutions of qi deficiency into three main components of two definitions, 19 symptoms and signs, and 15 risk factors. The two definitions address the holistic functional decline of in the human body or specific
functional decline of in certain viscera, rather than a lack of any essential material. The nineteen symptoms and signs can be gathered from the four classic four examinations of TCM. The fifteen risk factors are related to the patients’’ lifestyle and illness history in childhood and adulthood, which stressinged the long-term effect of exhaustion on the induction of qi deficiency patterns.
Acknowledgements
This study was supported by CCMP95-TP-039. We want wish to acknowledge the following organizations and individuals who recommended experts to participate in the Delphi process: Committee on Chinese Medicine and Pharmacy, Department of Health; School of Traditional Chinese Medicine in Chang Gung University, Formosa Association of Clinical Diagnosis in Traditional Chinese Medicine, Taiwan; Taipei city hospital; and
Taiwan TCM association (all in Taiwan); and Chengdu university of TCM; and Beijing university of Chinese medicine (PRC).
Finally, we wish to acknowledge the following individuals who agreed to participate in the Delphi process: Deng Zhongjia, MD, Prof; Zhang Tingmo, MD, Prof; Zhang Zhiwen, MD, Prof; Yan Shi-Lin, MD, Prof; Wang Cheng-Ping, MD, Prof; Lu Zhaolin, MD, Prof; Li Feng, MD, Prof; Qingye Li, MD, Prof; Liu, Jiayi, MD, Prof; Wang Lu Fen, MD, Prof; Fan Qiao-Ling, MD, Prof; Wang QingQi, MD, Prof; Yuan Zhao-Kai, MD, Prof; Yee-Guang Chen, MD, Lecturer; Chen, Yu-Sheng, MD; Chen,Jian-Jung, MD, Ass. Prof.; Lun-Chien Lo, MD, Assoc. Prof.; Chung-Hsien Yang, MD, Lecturer; Hong-Jen Lin, MD, Lecturer; Yao-Chin Hsu , MD, Lecturer; Chu-Chang Tyan , MD, Ass. Prof.; Chen Hj, MD, Lecturer; Jung-Nien Lai, MD, Ass. Prof.; You, Jyh-Sheng, MD, Assoc. Prof.; Jiann-Jong Shen, MD, Prof.; Kuo Chung Chen, MD; Chien-Lin Chen , MD, Lecturer; Chen-Hung Cheng, MD, Lecturer.
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