The Art of Taking a Case as postulated by Hahnemann

Supposedly there are as many approaches to taking a case as there are homeopaths. For the homeopath, at the very core of the patient-practitioner encounter, lies the deeper purpose of extrapolating from the expressions of the patient, sufficiently detailed information concerning the presented ailment or disequilibrium. This information retrieved during the consultation, is explored for the patient’s peculiar and idiosyncratic symptoms. Only from those unique and specific expressions can a best matching remedy be selected that most precisely meets the picture of the current presenting state of that particular patient. The art of finding the most appropriate, curative remedy is the fundamental purpose of homeopathic practice, and the greatest quest of the homeopath for his patients.

Hahnemann, in the Organon, gives specific descriptions of how disease is viewed in a homeopathic context, how remedies are made, how healing is expected to proceed, how a case is to be taken and much, much more. The following is a descriptive compilation of the directions Hahnemann gives to the practicing homeopath, in his Organon [1], on how to take a patient case.

Hahnemann begins to elaborate on the investigation into a case history as early as in Aphorism 6, where he pronounces characteristic traits that a practitioner requires when taking a patient’s case. He states that the homeopath has to be “…sharp-witted, but unprejudiced”. He continues in this Aphorism to describe, in a generalised form, what it is that the practitioner has to note in order to treat an ill patient. He stresses that a practitioner has to recognise “divergence of the human conditions from the healthy prior state…that which he [the patient] has perceived himself, his surroundings have found and the practitioner may note” (Aphorism 6). Hahnemann gets more specific in Aphorism 7, where he insists that attention must be paid to retrieving the totality of symptom expressions of the patient. He indicates that “It is the only means to convert illness to health”, and it is “… the primary, the only thing that a practitioner has to note and remove with his art…” (Aphorism 7).

Hahnemann further describes how a homeopath should go about retrieving, from the patient, the disease specific information. The practitioner is reminded in Aphorism 82 of the Organon of Medicine that he should be “meticulous in the appraisal of the plumbable symptoms and idiosyncrasies” of the presented disease, and is further cautioned that it is indispensable to strictly individualize each case of illness (Aphorism 82).

In Aphorism 83 then, Hahnemann  pronounces and emphasises, further characteristics that a practitioner should express when appraising an individualised patient case. Individualized case taking, so Hahnemann states, requires of the homeopath to express “ …nothing but unbiasedness, healthy senses, and attentiveness in his observation …”.  Hahnemann also urges in this aphorism that the homeopath should be “accurate in the note-taking of the disease picture”.

Hahnemann gives precise directions on how to proceed when taking a patient’s case. He proposes in Aphorism 84 that the following procedure should be followed:

         “The sick brings forth his discomfort.

         The family members tell of his complaint, his comportment and whatever else they have perceived on him.

         The practitioner sees, hears and notices by all other senses what is altered and unusual in the     patient.

         The practitioner takes notes in writing of all, and in the same expressions that the patient and his relatives used”.

In the succession of this aphorism Hahnemann stresses that the homeopath should not interrupt the descriptions that are given, unless the speaker were to drift to other topics. For the purpose of enabling correct note-taking Hahnemann suggests that the patient and his family should be reminded at the beginning of the consultation to speak slowly (Aphorism 84). Hahnemann even recommends clearly structured note-taking in order to facilitate amendment during the progression of the case-taking (Aphorism 85).

Once all persons have completed their narrations, so it is indicated in Aphorism 86, the practitioner should complement the descriptions of the case by adding specific characteristics to the symptoms. For this purpose the homeopath should have the patient ascertain each single symptom by further interrogating him for confirmation of the nature of the expressions of the complaint. As such the practitioner should seek further specification by asking about the time when a situation occurred, about occurrences before, during or after medication, about the nature, sensation, duration and location of pain. He should inquire the time of day or night and the bodily positions in which the symptoms are better or worse and should verify the exact occurrences of the causative circumstances (Aphorism 86).

In Aphorism 87 then, Hahnemann reminds us of an important aspect to keep in mind when taking a case. He emphasizes that the practitioner should not ask leading or suggestive questions as this could lead to imprecise responses. In fact the practitioner should pay special attention to utilize a general terminology that prompts the patient or other persons concerned to give particular comments (Aphorism 88).  Information that may not yet have been mentioned in the patients or relatives account of the diseased state, such as the bodily functions and dispositions should be explored at this stage. These include: “bowel movement, micturation, sleep pattern, temper, mood, reflective ability, appetite, taste, thirst, food preferences and aversions, comportment following food or drink intake, particularities of head, abdomen or limbs” (Aphorism 88).

Should the practitioner still feel he has not fully been informed, he should request further clarification to complement what he needs to know of the case. As such, specific examples are given by Hahnemann in Aphorism 89. Here he specifies supplemental questions for specific bodily functions, perceptions and sensations. Following this appraisal then Hahnemann indicates, that the practitioner should take note of what he himself perceives in the patient and his state. By further interrogation he should compare these peculiarities to the statements the patient has made earlier, and should note discrepancies in their diseased nature to that in a state of good health, so Hahnemann continues in Aphorism 90 of the Organon. Hahnemann further highlights this in Aphorism 91 where he stresses that the practitioner must always refer to the healthy state of the patient when appraising symptoms of the diseased condition of the patient. Only by comparison to the “original” state can the homeopath identify the “Gestalt”, the guise, of the illness.

Incidences and occurrences ultimately preceding a disease should also be noted. Hahnemann mentions these in Aphorism 93, where he indicates that such events may not be out rightly spoken of by the patient or his relatives. These, he indicates, should be sought to be extrapolated from interrogations that “fortunately” may point to such events, or should be found out by “private investigations” (Aphorism 93). He describes such events to be suicide attempts, alcohol dependency, unlucky love, jealousy, grief, and abuse; amongst others.

Customary habits need also to be investigated, as these could be causative factors of a diseased state. Hahnemann indicates that the removal of such habitual practices could facilitate the recovery from illness (Aphorism 94).

Once more Hahnemann points out that the practitioner should be meticulous in his case-taking, when he stresses that the appraisal of information, in particular of chronic diseases, should be “as accurate and detailed as possible, down to the smallest of particularities” (Aphorism 95).

In Aphorism 98 Hahnemann again cautions the practitioner and emphasizes what he already stressed in Aphorism 6 and 83.  Here he insists again that it requires “discretion, precariousness, the knowledge of human nature, cautiousness and much patience to investigate the true and complete disease picture and its details “.

Hahnemann finishes his elaborations on appraising a case, by differentiating the art of case taking of acute from chronic diseases. He reminds the practitioner in Aphorism 99, that the acute case of illness requires of him less investigation, but continues to stress the necessity to determine a detailed disease picture. Hahnemann indicates that the lesser duration of the acute state facilitates the case taking, as the details of the illness are still fresh in the mind of the patient and his relations, and explains that as a consequence the account of the presented state is likely to be more detailed and precise.

Hahnemanns instructions make clear that taking a case is a complex task that if carried out appropriately conveys to the practitioner the homeopathic remedy that is the closest match to the presented state of the ill patient. A swift recovery of the patient is therefore the reward for the patient’s detailed description, and the in-depth interrogation of the practitioner.

Hahnemann insists in his writings: “Imitate me, but imitate me correctly and meticulously” [2], therefore he gives practical instructions for the practitioner to follow. His ‘Organon of healing art’ [1] is not only a book depicting the fundamental principles of homeopathy, it is also an instruction manual that precisely outlines how a practitioner should execute his art. It conveys specific and practical information on the execution of the homeopathic art of practice, and advice for handling the diverse forms of disease situations. It even contains Aphorisms where Hahnemann cautions the practitioner and instructs on his behavior in the homeopathic consultation, as the above synopsis has shown. Hahnemann gave a valuable outline and its application falls to the practitioner.

References:

[1] Hahnemann, S. (1974). Organon der Heilkunst (2.Auflage) 6B Heidelberg:Karl F. Haug Verlag.

[2] Dr. Schweikert (1830). “Machts nach aber machts genau und sorgfaltig nach”, Zeitung der naturgesetzlichen Heilkunst für Freunde und Feinde der Homöopathik. Dresden/ Leipzig: Arnoldischen Buchhandlung.

first published at hpathy 2013

The homeopathic therapeutic relationship – a patient-centered union ?!

The alliance between homeopath and patient is a critical one. The homeopath, by way of the homeopathic principles, requires of the patient to share, reveal, and convey in explicit detail the nature of what ails him [5]. The patient needs of the homeopath, in order to feel secure and prepared to share such intimate information, that he provide a trusting and comfortable space in the consultation.

The homeopathic consultation is one that differs to that exercised in conventional medical practice. It is dominated by the patient and not by the practitioner. The contrary is customary in the encounter between general practitioner and patient. Here the patient assumes a passive role while the GP identifies what ails the patient and proposes a medicinal intervention [1]. The homeopathic patient-practitioner union is reliant on what the patient perceives as symptoms of the disease in his totality, and as such is therefore patient-led. This fact alone does not suffice to provide a patient with trust and ease in the consultation. Such sensitive union requires other elements or ‘tools’ in order to ascertain to the patient that his encounter with the practitioner is a safe and comfortable space. Person-centered qualities may facilitate what is necessary to establish such features in this union.

The ‘person-centered approach’ was first described and explained as such by Carl Rogers, one of the initiators of the humanist approach to psychology [2]. In the field of psychology and counselling, the focus of the practitioner is on activating the patients most inert resources in order for growth to be achieved. The believe underlying this concept is that the patient knows best of his own needs. The practitioners sole role is to aid the patient in accessing or recognizing these resources [3] [4]. Homeopaths can, following the principles underlying homeopathic practice, as is outlined in the Organon [5], borrow aspects from this approach in order to facilitate a comfort-zone to the patient, in the consultation. Yet, ‘patient-centered’ does not only mean that the focus is on the patient, his descriptions and narrations, but actually emphasizes much more on the practitioners presence within the therapeutic encounter [6] [7] [8] .

Of the 6 core conditions that inform the person-centered approach, in application to a homeopathic context, the following descriptions are useful to the development of a functioning therapeutic relationship:

The practitioner has to be there, qualitatively, with the patient   in the consultation. [6] [7] [8]. This he may express by being empathic and understanding towards the patient [7]. A form of mutual trust [4] of practitioner and patient aids in abolishing discomfort and may provide security in the therapeutic union. This trust may be further deepened by the practitioners expression of acceptance and non-judgement towards the patient and his case. Termed the ‘unconditional positive regard’, this requisite is an acknowledgement of the fact that every individuals actions are grounded on his very own personal reasons [9]. A practitioner may further deepen this trust if he is genuine toward the patient and if this is conveyed by the practitioners own authentic expressions arising from the patients descriptions in the consultation. The patient is then believed to be congruent towards the patient [10].

These attributes of the homeopathic practitioner may serve to create the ‘trusted zone’ for the patient, where he feels comfortable enough to disclose his ailing state in such detail as is relevant for the case-taking. Only if the idiosyncrasies, the most individual characteristics of the disease in the patient, by way of the patients own expressions, are reported, can the practitioner select the best matching remedy to suit the patients case [5]. A relationship that lacks trust and comfort may suffer of misinterpretation of the case-taking as the reported descriptions and expressions may have failed to inform the case sufficiently. The elements, native to the person-centered approach, are to an extent natural to the homeopathic patient-practitioner encounter, but the awareness of a patient-centered attitude that is expressed toward a patient, may facilitate its use as a tool to promote the creation of a trusted and comfortable union in the consultation.

References:

[1] Hartog, C. (2009) Elements of effective communication-Rediscoveries from homeopathy [online] Patient education and counseling Vol.77, pp.172-178, article from Elsevier, last accessed 02 October 2010

[2] Casemore, R. (2006) Person-centered Counseling in a Nutshell London: Sage publications Ltd.

[3] Pörtner, M. (2000) Trust & Understanding: The person-centered approach to everyday care for people with special needs Ross-on-Wye: PCCS Books.

[4] Wilkins, P. (1999) The relationship in person-centered counseling. Chapter 3 IN Feltham, C. (Ed.) (1999) Understanding the counseling relationship London: Sage Publications Ltd.

[5] Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg: Karl F. Haug Verlag.

[6] Lane, R., Koetting, M. & Bishop, J. (2002) Silence as communication in psychodynamic psychotherapy [online] Clinical psychology review Vol.22, pp.1091-1104, article from sciencedirect, last accessed 23 September 2010

[7] Nacht, S. (1963) The non-verbal relationship in psycho-analytic treatment [online] The international journal of psychoanalysis Vol.44, pp.334-339, article from PEP Web, last accessed 04 October 2010

[8] Freshwater, D. & Stickley, T. (2006) The art of listening in the therapeutic relationship [online] Mental health practice Vol.9, No.5, pp.13-18, article from Ebscohost, last accessed 04 October 2010

[9] Tolan, J. (2003) Skills in person-centered counseling and psychotherapy London: Sage publications Ltd.

[10] Merry, T. (1999) Learning & Being in Person-Centered Counseling Ross-on-Wye: PCCS Books, pp.85-117.

Science, evidence-based medicine and CAM…..it´s controversial!

Introduction

Patients are increasingly making their own healthcare their own responsibility, and are becoming more selective in what treatment and therapies they use in their recovery from illness. Dissatisfaction with conventional treatment that is indifferent of a holistic view of health, may produce more or less severe side-effects, or even concomitant diseases, makes patients seek new approaches for relief of their suffering. Frequently, the choice is an alternative and complementary medical discipline [1] [2] [3].

This happens much to the dismay of practitioners and representatives of orthodox medicine. They view the practices of alternative and complementary medicine critically. They describe CAM as being unscientific and treatments as lacking proof of effectiveness [2] [3] [4] [5] [6]. Yet, this critique itself needs to be viewed critically. The impression is that it follows a distinct purpose, may be far from justified and not necessarily reflects the best interest for patients.

Who says what science is?

Traditional Chinese Medicine and Ayurveda, beside others, are folk medicines that have withstood the test of time, and are in use since 2000 to 3000 years, treating their patients successfully with a holistic view of healthcare and disease [4] [7]. Only very recently, compared to the time-span of existence of the old folk medicines, came a novel, modern therapeutic approach, termed western medicine. This medical branch darted to the top, and became acknowledged as the principal approach to health care, having overtaken the older, traditional medical systems and having become, by implementation of frameworks and paradigms, largely the only form of patient health care acknowledged as scientific. The older, traditional treatment forms have increasingly, more or less successfully, been pushed into the periphery of medical practice, and are being discredited as being non-scientific according to the scientific standards that have evolved with the rising of this newer, allopathic treatment approach [4]. As such the newer western approach has become the conventional, allopathic medical system, and all other practices of medicine, the unconventional or alternative therapies [8].

The conventional approach demands all other treatment approaches provide evidence of scientificity of their practices, to be measured against those newly implemented conventional standards, in order to be acknowledgeable as safe treatment practice [4]. As such an evidence-based practice is sought to be created, whereby “individual clinical experience” is teamed “with the best available external clinical evidence from systematic research” [9](p.52). By insistence on this, practitioners of the allopathic medical route have over the years manifest their practice as the “superior” form of treatment, as scientific, evidence-based, against the methods of old that have been in practice much longer than the creation of the “young” allopathic medical concept, but do not meet up to the new scientific paradigm.

Viewed from a historical perspective, according to Riley [4], “the emphasis on science was intended to eliminate the unorthodox kinds of medicine” (p.552), to further modernization and improve the quality of medical practices. In his article Riley [4] demonstrates with the example of Thailand how, in particular from the USA, educational boards and foundations funded the establishment of orthodox medical schools and systems, seeking to promote digression toward the newer system of health care. In the consequence of such progression that took place in many countries during the colonization, as Riley mentions, an eradication of folk medical practices took place. This development was most successful in underdeveloped countries. In China and India, for example, this was less effectual, as the indigenous treatments there, TCM and Ayurveda respectively, had been successful since thousands of years without any dependence on scientific proof of efficacy [4].

CAM and science

The call for evidence of scientificity of the unconventional practices has in its persistence suggested that science is immediately a true fact and that consequently a therapy that is measurable by the scientific framework of conventional medicine, is equally as immediately a treatment that is efficacious [4]. This is not so. While it must be acknowledged that with the development and progression of science have come life-saving treatments that were yet unknown to folk medical practices, such as the identification and development of penicillin, it has to be noted that medical science has limits, and does not provide a cure-all for all diseases [4] [6]. In fact, the extent of “curing” disease under the label of medical science has been relatively small, the greatest praise having to be accredited to the improvement of hygienic conditions [4].

The demand for scientific evidence is flawed at the fundamental base-line of the claim, because, “although discrimination in the name of science is practiced, it is difficult to find an explicit basis for characterizing one specific medical system as more scientific than another” [4](p.549). Furthermore, there is lack of consensus as to what is to be considered as proof of evidence [5].

The notion therefore, that all therapeutic treatment approaches to health care, should be applicable to methods of allopathic testing and be thus supported by an evidence-base is unrealizable; too different are the underlying philosophies of the different disciplines [3]. Yet, to assume that the disciplines of CAM entirely lack evidence of efficacy is incorrect and to adopt the presupposition that the allopathic practices do is equally deceptive.

Investigations into the efficacy of CAM therapies have been and are problematic. Science follows the concept of a “materialistic causality” [3](p.669), and the CAM therapies fall short of fitting into the framework this concept of materialistic causality has generated. It appears that changes in the inherent world-view of the predominant scientific paradigm are necessary in order for the concept of CAM to be evaluable [10] [3]. The core of Sciences´ primary conflicts with the CAM practices, demonstrates dissonance of the conventional concept of standardization with that of individualization that is fundamental to the alternative, non-conventional practices [11]. As such therefore, the gold standard of the randomized controlled trial (RCT) as the principle tool for evaluation of efficacy of a treatment approach is rendered inapplicable, to investigations into holistic medical concepts of health [11].

Alternative therapies such as homeopathy, for example, have proceeded to adopt the testing methodologies inherent of conventional trials and studies, and are following the standard procedures as outlined by the Consort statement [13] (plus extensions [16]), but have extended investigations to include data specific of homeopathic treatment practice, by reporting on aspects that are outlined in the REDHOT guidelines [14].

While most trials and studies into CAM are undertaken with the focus of investigation being on the efficacy of the alternative treatment compared to placebo, Walach [5] insists that testing CAM therapies with the RCT should follow a different structure. He stresses that the holistic treatment is better tested against the efficacy of a treatment of another discipline as opposed to that of placebo. Riley [4] considers the placebo a bias to the claim of scientificity itself. “Placebos depend upon a patient`s (and perhaps a physician`s) belief that a therapy is likely to work” [4](p.556); a subjective experience, and therefore, science itself has an `unscientific´ aspect.

Is allopathy EBM?

Beside all the heated discussions and the persistent demand for evidence-based medical practices of CAM, one issue frequently receives little attention, namely, the extent to which the orthodox medical practices are in fact practicing what they preach and provide scientific evidence of efficacy. LaRiccia [8] and Patel [3] point out that few good quality trials exist that have investigated CAM therapies, but fail not to stress that this is likewise an issue in the evaluation of those practices described as evidence-based or scientific.

“Clinical Evidence comprises a database of high-quality, rigorously developed systematic overviews assessing the benefits and harms of treatments” [15](n.p.), and has proceeded to categorise the effectiveness of 3000 treatments with an astonishing and in fact shocking outcome. The data exhibited reflects to what extent treatments are evidence-based. The outcome of this categorisation has shown that a mere 11% of trials and studies show beneficial outcome, 23% are considered likely to be beneficial with the remaining 66% ranging from questionable, of unknown effectiveness, to ineffective or harmful [15].

Chart: http://clinicalevidence.bmj.com/x/mce/file/newchart20111028-1.jpg
Chart from: http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

 

This elevation draws into question the justification for the persistent and resolute demand for evidence of efficacy of CAM treatments. With so little profound evidence available from so called scientific medicine, the legitimacy of critique from the medical orthodoxy, concerning an insufficiently existent evidence base of the non-conventional practices, is questionable and appears shameful.

Why therefore, is the insistence on proof of efficacy of the CAM practices so persistently demanded, in particular from the conventional medical spheres? The reason becomes quite obvious if one takes into consideration the increase of interest in, acceptance of and use of CAM disciplines by ever increasing patient numbers. CAM has advanced to become somewhat of a threat to conventional medical practice [3].

The therapies of CAM are in existence because patients demand treatments outside of the conventional realm of medical practice [10]. Patients notice and experience that orthodox medicine has flaws [6]. They are not blind to the impact a course of treatment makes on them, to adverse effects or to the concomitant developments that frequently originate from the mainstream treatment of diseases.  Patients have become sensitized for their own well-being and health, and have therefore become critical of the handling of their discomforts and ailments [5] [6]. Consequently patients demand to be treated holistically, gently, alternatively.

Conclusion

Patel [2] stresses that an integrative approach to treatment may be most valuable to the patient.  He emphasizes that the factor `time of existence´ of a discipline is inappropriate as measure of efficacy, and that testing with standard scientific means is necessary for the acknowledgement of a non-conventional practice. Yet, he maintains that there are many challenges to such evaluation, and that CAM therapies should not aim at providing evidence of being a superior approach to healthcare. Rather should emphasis be on discovering “ the strengths and weaknesses of each system in order to be able to show that specific types of cases should be treated by specific holistic therapies, while other specific types of cases should be treated by scientific medical physicians” [2](pp.173-174).

If CAM practices were found to fully comply and be testable with the standard scientific methodologies, the alternative and non-conventional therapies would lose what makes them `different´. If CAM became scientifically standardised according to the orthodox scientific paradigm it would have to be incorporated into mainstream medicine and would consequently become conventional. The CAM practices would have to be reclassified, as specialities of conventional practice [10]. Is this at all favoured?

LaRiccia [8] points out that “the lack of RCT´s does not disprove a therapy”, and albeit Patel´s [2] call for CAMs compliance with the scientific methodologies of investigation, the traditional medical practices offer valuable concepts of health care. Practitioners cannot ignore the evidence of efficacy of a treatment that has been practiced successfully, and is documented by experience in practice, only on account of philosophical unacceptability within a fixed superimposed framework. It is the currently inexplicable that promotes investigation and has “in the past, been linked with significant scientific advances” [3](p.669).

References:

[1] Michlig, M, Ausfeld-Hafter, B. & Busato, A. (2008) Patient satisfaction with primary care: A comparison between conventional care and traditional Chinese medicine [online] article from Complementary therapies in medicine last accessed September 2012 at URL http://www.sciencedirect.com

[2] Patel, M. (1987a) Evaluation of holistic medicine [online] article from Soc. Sci. & Med. Last accessed September 2012 at URL http://www.sciencedirect.com

[3] Patel, M. (1987b) Problems in the evaluation of alternative medicine [online] article from Soc. Sci. & Med. Last accessed September 2012 at URL http://www.sciencedirect.com

[4] Riley, J. (1977) Western medicine´s attempt to become more scientific: Examples from the United States and Thailand [online] article from Soc. Sci. & Med. Last accessed September 2012 at URL http://www.sciencedirect.com

[5] Walach, H. (2009a) The campaign against CAM and the notion of “evidence-based” [online] article from The Journal of alternative and complementary medicine last accessed September 2012 at URL http://ehis.ebscohost.com

[6] Walach, H. (2009b) The campaign against CAM – a reason to be proud [online] article from The Journal of holistic healthcare last accessed September 2012 at URL http://www.ecpm-europe.ch

[7] Patwardhan, B. Warude, D, Pushpangadan, P. & Bhat, N. (2005) Ayurveda and traditional Chinese medicine: A comparative overview [online] article from Advance Access Publication last accessed September 2012 at URL http://www.ncbi.nlm.nih.gov

[8] LaRiccia, P. (2003) Point of view: A Physician´s experience with integrating complementary and alternative medicine: Opportunities, problems & directions [online] article from Seminars in integrative medicine last accessed September 2012 at URL http://www.sciencedirect.com

[9] White, B. (2004) Making evidence-based medicine doable in everyday practice [online] article from Family practice management last accessed September 2012 at URL http://www.aafp.org/fpm

[10] Chez A. & Jonas, W. (1997) The challenge of CAM [online] article from Am J Obstet Gynecol last accessed September 2012 at URL http://www.sciencedirect.com

[11] Yamey, G. (2000) Can complementary medicine be evidence-based? [online] article from West J Med last accessed September 2012 at URL http://www.ncbi.nlm.nih.gov

[12] Huffard, D. (2003) Evaluating complementary & alternative medicine: The limits of Science and Scientists [online] article from Journal of Law, Medicine & Ethics last accessed September 2012 at URL http://onlinelibrary.wiley.com

[13] Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. (http://www.consort-statement.org)

[14] Dean, M., Coulter, M., Fisher, P., Jobst, K. & Walach, H. (2007) Reporting data on homeopathic treatments (RedHot): A supplement to CONSORT [online] from The Journal of alternative and complementary medicine last accessed September 2012 at URL http://www.audesapere.in

[15] BMJ (2012) What conclusions has Clinical Evidence drawn about what works, what doesn´t based on randomised controlled trial evidence? [online] article from Clinical Evidence last accessed September 2012 at URL http://clinicalevidence.bmj.com

[16] Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG, for the CONSORT Group. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting parallel group randomised trial. BMJ 2010;340:c869. (http://www.consort-statement.org)

The controversial integration of Homeopathy into Conventional medical systems

The increasing demand for alternative and complementary medical treatment requests further discussions on the integration of CAM into conventional primary health care. The existent controversy concerning safety, lack of proof of effectiveness of the alternative therapy and in certain cases the absence of a regulatory body [1] [2] [3], have in the past raised heated discussions against the integration of CAM. But the increased interest of the public is impacting on the `conventional´ consultations, resulting in alterations of many a general practitioners stance toward CAM [3]. Patients´ quest for more autonomy in their health management, a fear of adverse reactions and the awareness of limitations to the allopathic treatment, has led patients to self-medication with alternative remedies and to dispense on private visits to CAM practitioners, outside the health system [3] [4]. Beyond that it is the congruence of the alternative approach to patients´ most personal beliefs and values, and the knowledge of a safe and effective treatment that is at the same time cautious of the patients´ orientation toward leading a healthy life [5] that has increased the awareness and acceptance of CAM therapies. General practitioners have recognized this trend, since they are often the first contact patients turn to for information regarding alternative therapies, and have attempted to adapt to this new tendency. Many that would in the past have had inadequate knowledge of the alternative and complementary methods have done training, permitting them to provide sufficient information about the alternative treatments available and the possible effects to the patients´ specific ailment [1] [2] [3].

One major step toward the integration of CAM is communication. This applies both to the practitioner-patient relationship and the cooperation between general practitioner and CAM-provider [3] [5] [6]. The need for collaboration between the two strands of health care practice is evident and could permit understanding and acceptance, resulting in an efficient service meeting patient requests [6].  Referral to CAM-practitioners usually occurs where a wider range of treatment options is sought to be available to patients, and where allopathic treatment has been ineffective or has brought forth adverse reactions and side-effects [1]. For the general practitioner to be able to respond significantly to patients´ interrogations, about alternative and complementary methods of treatment, requires handing the power of individual and personal decision making, back to the patient. As such it is assured that the ethical principle of autonomy is met and one essential point for successful integration of CAM into health care is fulfilled [2] [6]. Non-maleficience is another ethical factor that is thoroughly questioned when discussing integration as there is a lack of agreement over the scientific evidence of available CAM therapies [1] [7]. Available evidence of the effectiveness of CAM practice has already suggested a legitimate incorporation into primary health care but is still questioned due to the differences to conventional practice such as conception and interpretation, context of health and ailment, as well as the deviation in the relationship to science [2].To the general practitioner the CAM therapies are often still a challenge, because here practice is taking place in a zone that lies outside of the boundaries of conventional health care, in an area where the general practitioners training may not fully permit him to accept and understand the restricted but growing scientific body of evidence available [3] [7].

It has also been questioned if integration of CAM into conventional health care is, beyond questioning the feasibility of it, at all to be aspired [2]. Profound alterations could occur if evidence-based CAM treatments were fully integrated. By repressing CAM into the boundaries of conventional practice, CAM may be altered in its foundations, becoming standardized, resulting in the loss of it as an alternative option, and a merging of the two health strands beyond the identifiable features of CAM-practice [2]. Pro integration stands another factor, that of the financial aspect. CAM practice has been identified as being potentially cost saving in the long term, since expensive conventional treatments could be avoided and repeat consultations may be reduced. Arguments opposing this are of increased NHS spending on CAM, fearing the possibility of reduction of monetary funding and expenditure on other sectors of medical care [3]. Constituting a major factor opposing integration is the scientific evidence and the lack of research into CAM therapies [1] [2] [3] [5] [6] [7]. Ernest et al [6] go as far as to claim no reliable risk-benefit assessment can be undertaken in CAM to confidently confirm beneficence is greater than the risks possibly associated to CAM treatment. Controversy here exists, as funding for further research that could provide evidence for the safety and efficacy of CAM, usually goes into other sectors of medical research where existent evidence already promises efficient results for the justification of the research to be conducted [6].

In summary there needs to be said that for a successful integration of CAM into conventional health care practice, general practitioners are required to have a basic knowledge, from reliable source, of the CAM therapies that are available [1] [2] [3] [5]. There is the requirement for clear guidelines concerning referral and administrative issues [5]. Referral and cooperation with CAM practitioners has to be reliable, safe and efficient [1] [6]. From the point of view of the CAM practitioner, he needs to continually expand his knowledge in his field and should be prepared to seek assistance and advice on medical issues outside of his field from a general practitioner [1] [5].  For the cooperation of both the CAM provider and the general practitioner there is the need of intensive communication [3]. Conventional diagnosis prior to CAM treatment is an advisable feature of integration [1] and the interaction should result in CAM complementing general practice and vice versa conventional treatment supporting CAM for a successful integration to take place [5].

[Many thanks to Ian Townsend, University of Central Lancashire, U.K., for his assistance with this assignment]

References:

[1] Grace, S., Velmupad, S., Reid, A.,Beirman, R. 2007 CAM practitioners in integrative practice in New South Wales, Australia: A descriptive study [Online] last accessed 27.01.09 at URL http://www.sciencedirect.com

[2] Kerridge, I., McPhee, J. 2004 Ethical and legal issues at the interface of complementary and conventional medicine [Online] last accessed 26.01.09 at URL http://www.mja.com.au

[3] Maha, N., Shaw, A. 2007 Academic doctors’ views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study [Online] last accessed 06.02.09 at URL http://www.biomedcentral.com

[4] Dumoff, A. 2004 Legal issues presented by integrative health care practice [Online] last accessed 27.01.09 at URL http://www.sciencedirect.com

[5] Frenkel, M., Borkan, J. 2003 An approach for integrating complementary-alternative medicine into primary care [Online] last accessed 07.02.09 at URL  http://fampra.oxfordjournals.org

[6] Ernst, E., Cohen, M., Stone, J. 2003 Ethical problems arising in evidence based complementary and alternative medicine [Online] last accessed 21.12.08 at URL http://jme.bmj.com

[7] Adams, K., Cohen, M., Eisenberg, D., Jonsen, A. 2002 Ethical Considerations of Complementary and Alternative Medical Therapies in Conventional Medical Settings [Online] last accessed 26.01.09 at URL http://www.annals.org

In a nutshell…..Intercurrents

According to a dictionary definition an intercurrent is something that occurs” during or in between” two events. In medical terms it applies to a “pathology occurring during the course of another disease” [1]. This appears to be a very simple definition but in application of homoeopathic treatment the issue is slightly more complex.

Koehler [2] in “The Handbook of Homoeopathy” describes an intercurrent as an intermediary drug used for a patient where the best selected drug does not achieve a permanent cure. Yasgur [3] points to its ability of providing motion in a halted case, while Farrington [4] pronounces its efficacy in bringing the indications for a follow-up prescription to the foreground, and restricts its usage to times when the patient has only shown little reaction to the initial prescription.

So, one could say an intercurrent is a tool to apply if one seeks to identify the underlying aspects of a disease, that have not been touched by the previous, well-chosen homoeopathic prescription.

Hahnemann [5] mentions in Aphorism 234 of the Organon that in non-febrile morbid conditions and recurrent fevers homoeopathic China has been a useful intercurrent. Opium also served well for this purpose.

In the `Encyclopedia of remedy relationships in homoeopathy’, Rehman [6] describes intercurrents as “reaction-remedies”, coming into effect if there was no, or little action of the initially administered remedy. He also states their use as interim remedies between two adversary or incompatible remedies. Such remedies should not follow up on one another, and therefore require an intermediary prescription. This may be the case for example, where Hepar sulf. is to follow onto Mercurius sol. or Silicea, or where Nux vom. is needed to complement Causticum or Phosphorus. Rehman [6] also praises the application of the intestinal-nosodes as Intercurrents for the purpose of unravelling a case. He states that these nosodes make the previously administered remedy spur into action. The intestinal-nosode itself has no effect other than the unravelling of the symptom-jumble.

The use of intercurrents has to be differentiated further, as there are acute and chronic applications. Schepper [7] points to Aphorisms 36 to 40 for the use of intercurrents in an acute case. Here the intercurrent remedy is used to to treat the acute crisis of a case. If a chronic prescription were made in such a case, the symptom picture of the patient could be altered and undesirable aggravations could be the consequence. Therefore an acute intercurrent in a chronic case is selected by only taking into account the prominent acute symptoms and not the deeper chronic case history. As such, the acute intercurrent is a superficial agent that is used to remove the influence of the acute disease, without having an impact on the constitutional treatment of the chronic case. Hahnemann [5] describes this in Aphorism 221 of the Organon: The constitutional/chronic treatment has to stop when there is an acute crisis. Once this acute intermediate state is over, the chronic one will continue.

According to Little [8] in the chronic case an intercurrent is frequently necessary where miasmatic interference is present in the case. Here the symptom picture may be unclear, or symptoms may be scarce. Once an intercurrent has removed the miasmatic layer, symptoms may show more clearly and an appropriate constitutional remedy selection may be possible. Koehler [2] describes this with relation to the remedy Tuberculinum. As an intermediate remedy, Tuberculinum is indicated where symptoms remain after the first prescription, and the symptom-totality expresses a specific miasmatic taint.

References:

[1] The free dictionary(2012) Intercurrent last accessed 15 May 2012 at URL http://www.thefreedictionary.com

[2] Koehler (1989) The Handbook of Homeopathy Vermont, Healing arts press.

[3] Yasgur, J. (2003) Homeopathic Dictionary New Delhi, B. Jain Publishers (P) Ltd

[4] Farrington, H. (n.d.) Homeopathy and homeopathic prescribing New Delhi, B.Jain Publishers (P) Ltd

[5] Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) 6B Heidelberg:Karl F. Haug Verlag.

[6] Rehmann, A. (2000) Handbuch der homöopathischen Arzneibeziehungen Heidelberg, Karl F. Haug Verlag

[7] Schepper, Luc de (n.d.) Using Acute Intercurrent or Intermediate Remedies in Chronic Diseases last accessed 15 May 2012 at URL http://www.drluc.com

[8] Little, D. (2007) Part 2: The chronic Intercurrents last accessed 15 May 2012 at URL http://www.simillimum.com