Cases – a puzzle or a mystery?

I was recently reading about the distinction between a puzzle and a mystery in a piece written by Malcolm Gladwell about Enron. He states that “a puzzle is a situation where you don’t have enough information.  If things go wrong with a puzzle, identifying the culprit is easy: it’s the person who withheld information. Mysteries, though, are a lot murkier: sometimes the information we’ve been given is inadequate, and sometimes we aren’t very smart about making sense of what we’ve been given, and sometimes the question itself cannot be answered. Puzzles come to satisfying conclusions. Mysteries often don’t.”

So let’s take all that and think about case taking and prescribing.  The parallel isn’t precise but I think it can be useful.  So puzzle or mystery?  I think it’s important to understand the distinction in each case before us.  If a case is a puzzle, if we think hard, we often realize that we’re missing a vital piece of information.  Either the patient didn’t volunteer it, or we didn’t ask it.  Whether it’s modalities or particulars – is it better to lie on the painful side or on the painless side, where exactly is the sweating on the body, which comes first – the chill or the perspiration – when these pieces of information are missing, we are faced with a puzzle.  And when we sense that something is missing from our case-taking, we’re faced with an even more complex puzzle, because we need to go over all our case-notes and find what we neglected to ask the patient, what information is missing.

But if the case is a mystery – we’re in a whole other ball park.  We know we asked all the questions.  We know we have all the information.  But the patient isn’t responding to the remedies we’re giving.  Often in such cases we retake the case, over and over again, but no new, dazzling piece of information comes up.  Here it is not the information, it’s how we’re connecting the dots.  What patterns we’re forming in how we view the information we’ve been given.  Maybe we’re putting more stress on recent developments when we’re really facing an old symptom that has morphed into different versions of itself over the years.  Maybe we’re putting more emphasis on physicals and we will only be able to resolve the case using mentals – or vice versa.  Maybe we’re getting bogged down in ancient history, when we should be looking much more closely at current presenting symptoms.

The reason I found this distinction so interesting in its possible application to case-taking and analysis is this: there is a tendency among homeopaths to take down much more information than needed during a case.  I remember during my training that you could always tell students who were finishing first year – they were suffering from constant chronic hand pain from writing down every word in live cases.  (yes, in the olden days not everyone brought a laptop to class, our caves didn’t have electricity sockets… ).  And then our case-taking and analysis is flooded with a tsunami of information – which is just too much.  From looking for a missing piece of information to solve a puzzle, we essentially create a mystery of finding a path through the deluge that is now our case, and trying to keep our heads above water in a sea of case-taking disorder.

I believe that when we begin working with each patient, the case should be viewed as a puzzle.  We want to make sure we have all the information we need to fill the boxes – if a patient perspires we need to know where, when, hot, cold, mental state etc.; we need to know actual facts, where, how much, hard or soft, internal or external, colours, textures.  We need to know presenting symptoms and background.  Prescribing is a function of viewing the relevant facts, examining the provings and literature on a small group of remedies, coming to conclusions.

But if we’re sure of a remedy and it’s not helping, we’re now faced with a mystery.  And as any avid watcher of thrillers knows, often the criminal is found when someone looks at the event board and arranges the facts in a different pattern.

 

Video presentation: Case-Taking in Emotional Trauma

Case-taking in emotional trauma can be much more effective if we have more clarity about what we want to learn from the patient.  I’ve set out a more focused way of working with cases involving emotional trauma in the video below.  I’ve disabled comments as I don’t always have time to keep track and reply, but if you’d like to comment please drop me a line on the contact form.

I hope you find this presentation helpful.

Beware of the interesting…

Penny farthings. So now you know

I have a friend who accuses me of being drawn by anything new, bright and shiny – by anything interesting, not to put too fine a point on it. And I have to admit, he is right.

So much in life is boring, especially for a homoeopath. We plod through tales of stools, stomach pains and ‘that niggling feeling I get in my head when I go to the bathroom’. We discuss sputum, coryza, leucorrhea, diarrhea and constipation ad infinitum. The floaters in the eyes ‘only when I look up’, the sinus pain ‘only when I look down’, the belching after eating and the incontinence after a pint…

And we have to wade through that morass (sorry about the image but there it is) looking for how the condition is individualized in the patient. What makes it better. What makes it worse. And how to handle the patient who can only produce one answer – ‘I don’t know’. We ask ‘how has your mood changed?’ We ask if the child is clingy now he has yellow-green discharge which we examine in great detail.

How can this not be boring? How much more interesting is it to say ‘who needs all this, just look at their face shape?’ Or ‘you have to discover the patient’s core delusion’! Or ‘what is their innermost sensation’? Or ‘what colours do they like’? And then the expression which justifies all. ‘Do this, and you’ll see it’s the key to homoeopathy / the key to solving the case / the key to the world, the universe and everything…’. It’s that sense of a locked door creaking open, a locked trunk delivering up its secrets if we only had the key…

Finally things are getting interesting.

Only problem is – those of us who are honest with ourselves, who are capable of seeing the Emperor’s new clothes for what they are, will find that in place of a shiny brass key we are holding a fat red herring in our hot little hands…

As Sherlock Holmes (required reading for all homoeopaths) probably said at some stage, the only key to a crime are the clues showing that a crime has been committed. The patient is basically an ongoing crime scene (yes, strange image but bear with me, m’lud…). The clues begin with what the patient sees, hears, smells, touches and tastes, what we see, hear, smell, touch (usually not taste but more dedicated physicians in olden times were not averse to tasting a steaming beaker of yellowish liquid for diagnostic purposes…). . And ditto for the patient’s friends and relatives. The clues begin with what changed, leading to this crime. The detective frequently asks “Did he usually eat…drink…travel in this direction…ride a penny farthing bicycle…” because changes, in any good crime fiction, are the key to solving the puzzle.

The clues do not begin with whether the person on whom the crime is being perpetrated has a pointy chin and eyes spaced wide apart. The clues do not begin with whether his parents loved him, hated him, or dressed him up in women’s clothing. The clues do not even begin with his deep and enduring love for chicken…The clues begin with the victim of the crime (a.k.a. the patient) there in front of you, and with the information that has relevance to the crime. Or to switch back to homoeopathy – the information that is pathological.

Can you imagine the scene in a courtroom before a judge if the following happened?
“M’lud, I put it to you that my client was the victim of attempted murder”
“And how would you support your claim?”
“It’s clear, M’lud, he was wearing a brown jacket at the time, and has sunken cheeks.”
“Does he usually wear brown jackets?”
“No, M’lud, he has been known to wear green, or even yellow ones, but brown is his favourite.”
“And the sunken cheeks?”
“Oh, M’lud, it is known that people with sunken cheeks are usually victims of attempted murder…”
Thud of gavel.
“CASE DISMISSED!”

Is anyone reading this waking up to what is happening in homoeopathy? Please don’t tell me that it’s only thee and me…and lately I’m not too sure about thee…

The presenting symptoms which have changed are the only starting point that has any validity in homoeopathy. It is the only place where we can seek certainty. Of course there is more, every homoeopath has been deluged with information from patients at one point or another, all of it apparently relevant. But every homoeopath should be extremely wary of those bright shiny non-symptoms, which lead to even brighter, shinier and above all, interesting (and also  harmful) speculations.

The place where homoeopathy becomes interesting, to me, is when a constellation of really useful, 100% certain symptoms come together to closely mirror the proving of one remedy only. And the place where homoeopathy becomes fascinating and rewarding is when after prescribing, the patient calls to say a problem she has experienced for years is shifting and easing. And that, my friends, is the true bright shiny thing that is homoeopathy.

How confident are you? How confident should you be?

On confidence:

How confident should we be as practitioners? This is a question which worried me greatly when I started out. I felt uncertain (not surprisingly as I was entering the world of sickness and health armed with a copy of Kent’s repertory – a copy of which a colleague justly through out of a window in a different continent – and some basic core delusions about Sankaran’s teaching.). I was qualified, I had the grades, supervised clinical work and diploma to prove it. And after all that training, I did not feel confident.

It will come, some said. The more patients you work with, the more confidence you’ll feel. Until a cold voice cut through the general internet babble, as a colleague (armed with a handbag full of plumbum crude – if you’re reading this, you know who you are) said sharply “if you’re not confident in what you’re doing, you shouldn’t be practicing.”

I see my own inner debate of that time reflected in many forums, where some few honest souls admit to worry and lack of confidence. With hindsight and its freedom of constraint, I see that confidence, for a homeopath, actually relates to at least two separate issues.

We must feel confident in our tools. If we do not feel confident in the principles of homoeopathy – not a blind faith but a clear understanding of the rationale of our practice, if we only know how to parrot “like cures like” without understanding what that means and more specifically, what that demands of us – we really should not be practicing. If we do not grasp that there is a quirk and a default in nature, whereby a stronger similar disease can annihilate a weaker one and will always do so unless something else is standing in the way of cure, whether it is a maintaining cause or a deeper inherited miasmatic taint – if we don’t get that then we really should not be practicing. We’re not talking about confidence in our ability. Here this is the confidence that our tools work. That “like cures like” is a prescribing principle, not a holistic “airy-fairy” slogan.

Personal confidence is another thing altogether. We have to get used to working with patients, to eliciting the information we need for prescribing, to listening to our patients without interrupting, to allow the picture of the disease to take shape before our eyes. We have to keep studying Organon, materia medica, provings, Hahnemann and Boenninghausen’s writings and works of similar value to keep our abilities honed and our homoeopathic knowledge checked and re-checked. We have to gain confidence in prescribing, in case-management, in effective follow-up.

Personal confidence is something every practitioner gains in time – in any field. But without confidence in our tools, that personal confidence is worthless. It’s worthless in the sense that if we are genuinely trying to work according to principle and don’t understand it, our confidence is a thin shell, a shiny veneer covering a world of insecurity in practice.

However, the worst expression of the worthlessness of personal confidence without true professional conviction is that those bumping up their levels of such personal confidence to overcome the lack of professional conviction are drawn to the new and the shiny, to developing their own new and shiny theories to astound the world.  As a result, they never investigate the tools properly, and learn to work faithfully and honestly to principle.

Something Hahnemann said in the Organon within a slightly different context seems an apt quote to close this post:

“A true homoeopathic physician, one who never acts without correct fundamental principles, never gambles with the life of the sick entrusted to him as in a lottery where the winner is in the ratio of 1 to 500 or 1000 (blanks here consisting of aggravation or death)…” (note to Aphorism 285).

Remedy outcomes and case management

What is happening when you give a remedy, it holds for a short time only and the symptoms return? What questions will you ask yourself as you decide what to do? The objective of this article is to open up a more precise form of discussion of remedy outcomes and case management. The suggestions I’ve made below based on Hahnemann’s discussion of similar and dissimilar disease actions in nature are just that – suggestions.

Empathy in case-taking

This article was prompted by a discussion with a colleague regarding an old post of mine, entitled “What We Know and What We don’t Know”. Our discussion took us into the subject covered by Dr. Gary Weaver’s original post, on “The Realities of Practice”. In his article, amongst other things Gary set out a prescribing process for a busy clinic where 40-100 patients may be seen a day by splitting up case-taking between one prescriber and two or three nurses or advanced students.  The main symptoms of the case are elicited by the prescriber’s assistants.   The patient is then brought to the prescriber for further questioning, analysis and prescription. This kind of clinic is more common in India, and much less common elsewhere. Many, if not most of us work privately with patients, and I don’t know if any such volume clinics exist in the West.

The point, however, is that clear symptoms may be taken by the assistants within 20 minutes, and that deeper investigation and analysis should not take the prescriber longer than a further half an hour, often much less.

The Kentian Call of the Constitutional Remedy

constitutional: a walk or a run, ultimately bringing you back to where you started…

The Kentian Call of the Constitutional Remedy

A theory of everything (ToE) or final theory, ultimate theory, or master theory is a hypothetical single, all-encompassing, coherent theoretical framework of physics that fully explains and links together all physical aspects of the universe. (Steven Weinberg. Dreams of a Final Theory: The Scientist’s Search for the Ultimate Laws of Nature. Knopf Doubleday Publishing Group.)  (thank you, Wikipedia…)

Case-taking and analysis: “knowing” versus “thinking”

Cogito ergo erro…(sorry, Descartes)

As homoeopaths we must be aware of perhaps the no. 1 pitfall in analyzing a case.  And once you notice it – it cannot remain un-noticed.

Homoeopathy is not a therapy based on hunches or intuitions.  It is a therapy based on observation of fact, and knowledge.  Just go back to the Organon aphorism 3 – or simply consider the obvious.  The homoeopath’s job is to observe and elicit the information about the disease (case-taking), to know what is curative in remedies (knowledge of provings, poisonings and clinical experience), and to find the appropriate remedy, administering it with appropriate potency and dosing.

Taking the case – and the teacher’s dilemma

TAKING THE CASE – AND THE TEACHER’S DILEMMA

Recently my colleague Gary Weaver posted an article by Carol Dunham on case-taking. The article was wise, learned, extensive and – let’s face it – somewhat wordy. Extremely wordy.  So on an initial reading, the brilliance of the actual comments regarding case-taking becomes dulled, presented within an analytical and theoretical context which is either familiar from the Organon, or Dunham’s own form of analysis which is not a matter of consensual self-evident fact.

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