Installment One, Section 1
This is the first chapter of an extended book-length essay on homoeopathic case analysis strategy I'm developing, which will be published in serial fashion here on the WholeHealthNow website. Anticipate a new installment on a monthly basis. These articles originate largely out of material I've prepared for teaching at The School of Homeopathy, New York.
Return to this site monthly for this ongoing series. New features will be posted around the first of each month.
Throughout these articles, I will repeatedly refer to Hahnemann and other masters of our classical tradition. There are those who would detract me on this point with Leonardo daVinci's quote about reliance on authority; to whom I would merely reflect in kind for their reliance on the authority of Leonardo; but also reply, that there is little "new under the sun" in homoeopathic practice that is not well-anticipated in Hahnemann's writings.
As the foundation of successful case analysis is a well-taken case, I thought it best to call this series "Taking the Case"
© Will Taylor, MD 2001 (bio)
Installment 1 of a series on case analysis:
Once the totality of the symptoms that principally determine and distinguish the disease case - in other words, the image of any kind of disease - has been exactly recorded, the most difficult work is done. During the treatment (especially of a chronic disease), the medical-art practitioner then has the total disease image always before him. He can behold it in all of its parts and lift out the characteristic signs.
- Samuel Hahnemann, Organon of the Medical Art, §104
In taking a case, we are asked to simultaneously take on two seemingly conflicting roles; these being to listen and observe carefully, free from bias, to the spontaneous presentation of the patient; while on the other hand, being carefully attentive to and cognizant of what is unusual or characterizing in this presentation. This requires that we tread a narrow line, from which we will likely often inadvertently deviate, to meet the narrow reality that exists in the juxtaposition of:
Unprejudiced observer <- -> Alert to Recognition ("Eyes on the Prize")
Hahnemann tells us:
This individualizing examination of a disease case demands nothing of the medical-art practitioner except freedom from bias and healthy senses, attention while observing and fidelity in recording the image of the disease.
§83, the Organon
He makes it sound so straightforward! How do we walk this narrow line, remaining unprejudiced in our taking of a case, yet keeping our eyes always on the "prize" of a revealing totality? I have found it most useful to remain continuously cognizant of the apparent contradiction of these two roles we play in taking a case; knowing that I will often fall short in complying with one task or the other, and will need to accept this with humility, while recognizing the ideal of finding the narrow path that strikes through this apparent contradiction in role.
Acute vs. Chronic Presentations
Much of what is discussed below applies best to chronic casetaking. Hahnemann reminds us (aph.82), "In acute diseases, the principal symptoms become more rapidly conspicuous and discernible to the senses so that a much shorter time is needed to note down the disease image. Since most of the acute disease presents itself spontaneously, there is much less that needs to be asked. Gradually advanced, chronic diseases of several years duration are discovered far more laboriously."
The evaluation of acute and apparently-acute disease takes on its own character in many respects, and this I will reserve for a future article.
The Unprejudiced Observer
Let the Patient Talk
Perhaps the first directive is to allow the patient to reveal their own case, in their own manner. Hahnemann suggests that we keep "silent, allowing them to say all they have to say without interruption" (aph.84). My spin on this, is that were I to structure the interview, frame the questions, and record the interview in words most meaningful to me, I would be successfully acquiring the information I needed to identify my own homoeopathic remedy; rather than the one needed by my patient.
Perhaps the patient has been describing a recurrent headache. I may find myself dying to know whether it is ameliorated or aggravated by pressure, by heat, whether light or movement is bothersome, etc. I could easily interrupt to ask for this information, or take advantage of a short pause to ask more unobtrusively. But if I instead continue to listen, to allow the patient to spin their own tale, I may be somewhat surprised to hear them slide right in to talking about their relationship with a co-worker, and their thoughts about making a career change. Now there is some logic in my patient's brain that links these things together - some richness of the patient's terrain that I would have entirely missed, in order to obtain information about some modalities that I could always have come back for.
What is more interesting, more characterizing of the disharmony of this individual patient? The modalities that I think I need to know; or the story that the patient believes they need to tell me?
It is much for this reason that I do not use health-history questionnaires, or review medical records before an initial interview. I do not want the patient to assume that I know anything about them before the interview, and therefore assume that they can afford to leave anything out. I want to hear their story.
An elderly woman consulted me for an initial visit, and consumed the entire two-hour interview talking about seemingly everyone, except herself. Why her husband should see me, and her daughter, and what was wrong with conventional medicine, on and on for two hours, without room for any redirection from me. The few times I did manage a word in edgewise, she artfully slid off questions about herself onto other topics. All the while tugging at a stretched-out mock turtleneck sweater she was wearing. I didn't even have a presenting complaint at the end of the interview. As I sat afterwards, feeling sorry for myself for having nothing to prescribe upon - alternately dumping on myself for having taken a poor case, and upset with the obstacles to obtaining a clear case - I suddenly realized that in fact I had a great case staring me in the face: Loquacity; Desire to Hide; and Cannot tolerate tight clothing about the neck. If it was a snake, it would'a bit me! I mailed her a dose of Lachesis, and saw her in followup 4 weeks later, when she informed me that she was "100% better". She sat silently waiting for my response.
I asked her to call me if it ever came back, and asked her to please not tell me why she had consulted me in the first place! My secretary periodically checked in on her by phone and two years later, when my curiosity finally exceeded my sense of mystery and intrigue, I asked her to send me her medical records. She had had polymyalgia rheumatica, an autoimmune inflammatory polyarteritis; remaining now asymptomatic, with lab tests returned to normal, off all allopathic meds since her initial visit to me. Had I obtained a "good" medical history, structuring it in order to obtain full symptom descriptions, modalities, sensations, etc. etc. I might still have found the simillimum for her case. However, by allowing her to weave her own story, the remedy picture was strikingly clear, even without - and perhaps even unobscured by - the kind of information I thought I needed.
Much of the story of the case is told between the words of the delivered history. Some patients will rattle out a rambling two-hour narrative, as the one above. Others will deliver a carefully organized chronology of events with accurate dates and measurements. Some will name their complaint briefly, ask what homeopathy does for it, and wait for a reply. It is important to reflect not only on "what are they telling me", but also "how are they telling me?" and "why are they telling me this, like that?" In addition to content, we need to make observations of context, delivery, and affect.
I had a sweetheart back in college, who I thought was madly in love with me. She always leaned forward, her face right in mine, when we talked. Turns out she was nearsighted. What about the patient who slides their chair up close to yours in a spacious consultation room? Do they want to connect, or did they forget their glasses?
It is far too easy to project interpretations on our observations. I like Jonathan Shore's bottom-line on this topic - how would you describe the person to someone who needed to pick him or her out in a train station? Specifics, not interpretations.
What is the nature of the patient's description of things? Are they theorizing about the origins of their symptoms? Or parroting previous providers or self-care book authors? Is their narrative overly censorious of the providers they've seen in the past? Or aggrandizing on the names of the prominent Baltimore surgeons who operated on their gallbladder?
I recall a case in which, at the end of 90 minutes, I felt totally bewildered. It was like this, no, actually, it was like that. Or like this. And, nothing helped, but this made it better. Or, maybe worse. But usually better. There was no useful content in the entire case! What there was, was tremendously useful context. Describing the delivery of the history - [GENERALS - CONTRADICTORY and alternating states] x [MIND - CAPRICIOUSNESS] - describing the delivery of the history - provided me with the center of the case.
Observation of physical features needs similar attention. Can we describe the facial expressions in the detail necessary to pick this person out in a train station? Even simple things such as a rash - rather than describing it as "eczema" - which is an interpretive statement, at once adding speculation to the description and losing detail - benefits from a description which enables one to reconstruct a picture of the rash in the mind's eye.
Pauses in the interview are there for a reason. They can feel uncomfortable. They can feel unproductive, and inviting of impatience. Yet, they can be the most productive element of an interview. Does the patient ask for structure ("What else do you need to know?") What direction does a patient take up spontaneously when resuming after a pause? Don't feel anxious to close pauses up with questions that could re-direct the interview; allow the patient to lead you out of them.
Waiting through an extended pause is something that many of us need to practice. There's a point where we start to squirm, start to feel embarrassed (for the patient? For ourselves?). However, waiting to see where the patient will choose to go after an extended pause can be very fruitful. Even "Well, that's about it" or "What else do you need to know?" can offer us a great deal of insight into the case.
It is often after an extended pause - when the patient has exhausted the story they've come prepared to give you, told you what they think you want to know - that they begin to be spontaneous and offer insight into what is genuinely real for them.
The most effective responses we can make during an interview are often those in which we remain relatively transparent, and allow our patient to retain direction of the process. A patient may direct a direct question to us - e.g., "So what do you think of that?" or "What else do you need to know?" - to which silence may not be appropriate, perhaps suggesting to them that we are actually asleep! A response such as "of " or "well, tell me more " or "what do you think is important for me to hear?" can move them back into elaborating or expanding on the topic. On reviewing my videotapes, I find my most common responses include simple reflective words, such as:
[Patient] "I really don't like driving over bridges."
A more detailed response - e.g., "Why don't you like bridges?" - may redirect the interview away from what the patient needs to tell me. E.g., had I responded, "Why don't you like bridges?" I might have received a useless intellectual explanation, such as, "Well, I know better, it's really kind of silly"; while a simple "Bridges?" might have resulted in a much more spontaneous, more useful response, such as "Yeah, bridges. And being late - I don't like being late to things either."
A Time for Answering Questions
Patients often have questions that they need answered. About homeopathy, about followup and practitioner availability, about the bag of supplements they've brought in to be gone over, about the name of their condition, etc. They often sprinkle such questions into the initial interview.
I let folks know at the outset that I'll collect their questions, and address them all at a later time, in the second visit or in a special visit arranged for extended patient education. When questions arise in the course of the initial interview, my relationship to them is not that they are questions that need answers now, but rather that they are expressions of the patient that can lead to my understanding of the case.
E.g., a patient may feel entrenched in the idea that they have "chronic yeast syndrome," and ask numerous questions about this - could it account for this symptom, what does homeopathy do for this, etc. These are questions that may deserve to be addressed, but not in the initial interview. Return to them later - I choose to do so in a second visit - but listen to them now as expressions of the patient, as valuable as any other symptom expressed in the case. Is the focus on "yeast syndrome" evidence of theorizing? Impressionability? Anxiety about health? Continued listening may make this clear.
Avoid Projections, Assumptions, Speculation
I recall Jonathan Shore stating that the two times one can fall into the most trouble in casetaking, are, first, when you hear yourself saying "no"; and second, when you hear yourself saying "yes". The times that we think we understand our patient - that we think we can relate to their experience - can be very dangerous places for misunderstanding in casetaking; it is here that we can too easily feel we are done listening, and move on to speculate, assume, or project our own interpretations onto a case.
A patient tells you that they are afraid of flying. You can record it as such, and feel ready to move on, but do you really understand this symptom? Do you hear "fear of heights"? Or "fear of closed places"? Or "fear of losing self-control"? How about "it's not being able to get enough oxygen, the air is thinner up there, I have this thing about suffocation", as one patient recently elaborated on this fear to me? Speculation, assumptions, or projections of one's own experience won't suffice except to misdirect here.
Abuse history is a very difficult topic re projections and speculation. Practitioners who have histories of abuse, and those who do not, all have their own personal buttons pushed by this topic when it comes up. Can we hear this in a case, and feel that we understand it as "ailments from abuse"? I'd suggest not. "Ailments from abuse" reminds me rather of "Ailments from tall buildings collapsing on you"; I'd be more intrigued by the person who experienced abuse without sequellae. So, the question becomes (if an explanation does not follow spontaneously) "If you and I were to write a book about abuse, we could fill hundreds of pages with what's wrong about it. So for you, what would be on page one?"
Avoid Preconceptions about the Topology of Disharmony
We never know ahead of time where out of the case, or in what form, the characterizing totality of symptoms will crystallize. One great impediment to effective casetaking is to enter a case with the expectation that the characterizing totality will present in any particular way - e.g., to anticipate that it will invariably be best revealed in the mental/emotional picture; or in a characterizing physical pathology; or in keynote symptoms; or in the gestalt image of a remedy "essence". I take great issue with individuals who describe themselves as "keynote prescribers" or "essence prescribers" or "mental/emotional prescribers", and feel that such one-sided approaches to casetaking can only restrict a truly flexible and creative approach to casetaking and case analysis. Flexible, creative and robust casetaking and case analysis require allowing your patient to take you where they need to go - rather than attempting to force your patient to fit a preconceived mold defining the shape you expect their disharmony to be.
Saying this, I also feel that we can learn a great deal from those who advocate "specialization" in such approaches; but only if we do so in an expansive, rather than restrictive, manner. I have seen a case in which Nandita Shah - of the Bombay school associated with Rajan Sankaran - prescribed for a chronic case guided principally on the sensations and modalities of a cough. It is this ability to identify, creatively and flexibly, the characterizing features of a case, which demarcates a truly effective prescriber.
We are asking ourselves to multitask at an unprecedented level when we attempt to prescribe in a chronic case at the close of an initial interview. While this is feasible - and most generally necessary - for cases of acute illness, it strikes me as being quite unreasonable in working with most cases of chronic disease. I arrange a second visit a few days to one week after the initial consultation, at which I suggest a remedy, having the intervening time to study the case in depth. To expect to prescribe at the close of an initial interview is to ask oneself either to prescribe "intuitively" (a task which James Tyler Kent and Ernest Farrington agreed would require 30 years of careful experience in casetaking and analysis), or to distract ourselves from unprejudiced casetaking with simultaneous analysis during the interview process. Obviously there will appear to be exceptions - occasionally God and Hahnemann collaborate to send us a case that screams its simillimum at us in an unmistakable manner. However, there have been sufficient such cases screaming "Sepia" to me that have turned out to eventually need Trillium (e.g.) to convince me that even such "obvious" cases are deserving of formal analysis, and the focus of the initial visit on unprejudiced casetaking that this permits.
Section Two: When We Feel Pulled from Unprejudiced Observation