Installment One, Section 2

When We Feel Pulled
from Unprejudiced Observation

What can we do when we find ourselves pulled to stray from the ideal of Unprejudiced Observation? What can we do when we find ourselves saying "yes" to a remedy, or feel we cannot wait another moment to know the modalities of a headache as our patient is wandering off into another "aside", or when we're saying "yes" to a supposed understanding of the experience of a patient?

First, it is helpful to parallel the dichotomy of {Unprejudiced observer <- -> Alert to Recognition} in the structure of your notes.

There are many ways to do this. With the body of my notes reserved for recording the disease-image in the patient's own words, I use the right margin of my notes for "impressions". Not so much to record these as valuable items for future use, but to discard them from my thoughts so that, having done this respectful duty to my impressions, I can return to unprejudiced listening to my patient. I may find at the end of recording 4-6 pages of visit notes, 3-6 notes of remedy names in the right margin; and perhaps the name of an allopathic disease category. I rarely find these notations of much use when studying the case; but recording them helps me feel that I've done my duty to them.

The left margin can be reserved for items to "go-back-to" - e.g., left of the patient's words describing a headache, can be the symbol "<___" reminding one to come back at the end of the interview for aggravating modalities. Left of a rambling story can be "??" reminding one to come back to this for elaboration. Hopefully these "holes" in the case will be completed by the patient spontaneously as the interview progresses - but by noting these as you go along, you can dispense from your mind your duty to come back to these points, and return to active listening. At the end of the interview, you can come back to these reminders and complete them as you find necessary.

In the top right-hand corner of my first page of notes I record impressions re "obstacles to cure" - e.g., in a person who reports seasonal depression, I might note "?SAD? - Light therapy". I refer to these when organizing for the followup visit; when I'll discuss such things with the patient, provide them with self-care handouts, etc.

Such notes serve a dual purpose. One function, obviously, is to have reminders for future use. Just as importantly, these written reminders now serve to allow you to put these thoughts, impressions or concerns out of your mind, so that you can return unburdened to the role of an unprejudiced observer.

What is it in a case that we are asked to be Alert to Recognize?

Knowledge of People

The first, perhaps, is a knowledge of people (or dogs, horses, iguanas, etc.; we treat all kinds). Where can such knowledge come from? Certainly in part, at least from our life experiences. Yet, the nature of information shared in the homoeopathic interview is often of a privileged sort, which we are unlikely to encounter outside of a clinical setting. This understanding of people, or critters, will grow with experience in practice, as a continuing gift from each individual we encounter in this privileged setting. It will range from terrifying to illuminating. I find myself deeply moved, often to tears, by peoples' stories of survival and recovery; terrified by their stories of fears and disempowerment; bored to death by their stories of mediocrity; embarrassed by stories of benevolence and generosity far greater than my own feeble efforts; repulsed by arrogance and greed; and alternately entertained and confused by incredulous stories that I struggle not to dismiss as too fabricated.

From this, we can begin to recognize what is weird and what is normal, what separates the disharmony of our patient uniquely from the rest of suffering humanity.

Without a deep knowledge of people, we can fill pages of notes with unremarkable observations of common human traits. Trivially, we end up giving lots of Arsenicum for tidiness, lots of Sulphur for untidiness; too much Lilium tigrinum and Sepia for the two respective ends of normal sexual drive; etc.

Knowledge of Disease

Second, is knowledge of disease. By "disease", here I do not mean exactly knowledge of "the diseases" described according to allopathic pathology. There is a reality to the myriad forms of disease as reflected in the individual cases that come before us, which transcends the boxes created for their classification. Our recognition of each presenting case as unique unto itself, however, does not reduce homoeopathic pathology to a hopelessly nihilistic science. Although we cannot meaningfully speak of "scarletina" e.g. as a disease-entity-in-itself that directs our therapeutics (as it would to our allopathic brethren), our system of homeopathic pathology can recognize a Belladonna scarletina, a Bryonia scarletina, an Arum triphyllum scarletina, a (god forbid) Helleborus scarletina, etc.

Knowledge of our Remedial Substances

In this way, our Knowledge of Materia Medica parallels or mirrors our Knowledge of Disease - and our homoeopathic pathology and homoeopathic pharmacology become at once reflections of each other. This is an enviable state of affairs, for which allopaths would seemingly trade their eyeteeth! So third, is a knowledge of the Materia Medica, itself an extension, by similitude, of the knowledge of pathology.

One aspect of our knowledge of disease, is our knowledge of chronic disease - specifically, a knowledge of the nature of the chronic miasmatic diseases that manifest hydra-headed, as the chronic afflictions of mankind (horsekind, iguanakind, etc..).

Aspects of these knowledges of people, disease, and material medica will be covered at length in future installments in this series. In casetaking, what is important is that we are able to recognize what is characterizing in the case on these bases, what distinguishes the disharmony of this person, this presentation of disease, from the remainder of suffering humanity.

Recognition of Complete Symptoms

Boenninghausen described for us the Dimensions of a complete symptom, including Locality, Sensations, Modalities, and Concomitants. Cognizance of the dimensionality of a complete symptom is important in case analysis, but in casetaking, it can help us to recognize when we have a complete case, and when we need to know more. It is not unusual to find oneself at the conclusion of a case, and realize e.g. that though we have a good description of locality and sensation of the core symptoms, we are missing any modalities. Making marginal notes - as described above - to remind us of this during casetaking, and at the end of the case going back to "harvest" these missing pieces as much as possible, can help to assure us of a complete case when we take it into the stage of analysis.

The next two installments in this series will address the Dimensions of a Complete Symptom - first, a discussion of Boenninghausen's dimensions, most applicable to physical symptomatology - and following that, an investigation of the characterizing dimensions of a mental/emotional symptom.

Polarities / Apparent contradictions

Frequently in listening to a patient, we will notice apparent contradictions or polarities, things that do not seem at first glance to mesh. E.g., The quiet, shy, unexpressive patient who describes shrieking and hurling objects when angered. These are places to return to, in hopes of discovering the thin line of truth that runs unencumbered through the two apparently contradictory realities. When I come across such apparent contradictions in casetaking, I mark each occurrence in the left margin with the symbol "<_>"; and return at the end of the interview to learn more, if it has not been forthcoming spontaneously.

Completion of the Case

The majority of the case is obtained in our role as "unprejudiced observer", allowing the patient to reveal their own story. Often though, we need to complete the case with information that has not been spontaneously forthcoming, or appears to be incomplete. The time to do this is when it is clear that the patient's spontaneous delivery has accomplished what it can; at least for now. This will vary widely from case to case - for some, 2 hours will be just getting going - for others, we can feel like we're pulling teeth within 10 minutes. When long pregnant pauses no longer result in spontaneous narrative, that is when we can fruitfully begin directing questions. As always, Hahnemann has paved this path for us:

When the narrator has finished what he wanted to say of his own accord, the physician enters a closer determination of each particular symptom.
Aph.86

This is when I come back to those marginal notes, and aim to complete the descriptions of symptoms, obtain clarification of stories, apparent contradictions, etc.

In phrasing questions at this point though, it is important to recognize that your role is still that of an unprejudiced observer. You've taken a step across that apparent divide of:

Unprejudiced observer < - -> Alert to Recognition ("Eyes on the Prize"),

but it is important to retain a balance between being alert while still remaining unprejudiced. I like to keep the image of myself as a fencer at this point - with my question I put something out, but then immediately return to the role of observer. It is easy to become impatient when you don't feel your question is answered; you may ask for the aggravating modalities of a headache, but receive instead a long story about the doctors who've never listened or believed the patient in the past. You can feel impatient as you still don't know the aggravating modality, or you can be delighted to have one more confirmation in the case of the patient's deep-seated feelings of abandonment.

Often enough, a patient will ask me, "Did I answer your question?" A good response often would be, "No, but you answered the question that I should have asked." Always keep the essential question in mind - whose interview is this, anyway? The patient cannot fail to give you information about themselves; it is, after all, the only thing they can really talk about. Our questions - like the parry of a fencer - serve to bring out responses. It serves us best not to feel too attached to what these responses might be, so that our expectations do not eclipse our ability to hear the genuine expressions of the patient.

This said, you'd still like those modalities! So, try again, perhaps from a different angle, when the narrator has finished what he wanted to say of his own accord. It may be more fruitful to allow your marginal notation to remind you to return to this a bit later, while following up now on something more immediate in the story just delivered. Later, when you get around again to asking about those modalities, you might still not get them - but instead, learn that the headaches are in the left temple.

Open-ended Questions

The least helpful questions for us are those that can be answered in one word, particularly if that word is "yes" or "no". For intermenstrual bleeding, the question "Is the blood red?" is nearly useless - unless the answer is strongly "no". A patient with chestnut-brown blood may well answer "yes" - and we've not only lost an important characterizing symptom, we are misled as well. "What color is the blood?" is a bit better - but still not the best way of obtaining the information we need. Perhaps the most remarkable aspect of the bleeding is that it is stringy, and by the way quite dark, nearly black. Phrasing the question in a more open-ended manner - e.g., "Tell me more about the bleeding" - gives the patient the opportunity to tell us what is most remarkable about their symptom. So we may get "stringy" and still not know the color - yet this is really what we need to know. We may need to keep asking, perhaps finally in less open-ended ways, if we think we really need to know the color.

Upside-Down Questions and Overstated Queries

I recall a patient who told me he masturbated a lot. Now the question comes up, is this about increased sex drive etc., or is he being overly self-censorious about a relatively normal level of activity? Now if I asked, "like, more than once a week?" he might figure I thought that was a lot, feel demurred, and answer "no" or perhaps a simple "yes" but now feel intimidated about admitting to a much greater frequency. I could have asked an open-ended question, like "a lot?" or "like how often?" but again, I'm not sure I'd trust this to give me a reliable answer. So give him permission to come in under an outrageous figure - so it's OK if his reply is truly outrageous. So I asked, "like, three or four times a day?" Thinking this gave him permission to reply with something as outrageous as "no, just once or twice". (He replied, "sometimes, but more often like 6 or 7 times a day").

Wrapping it Up

There is a point in casetaking where you have the information needed to move on to case analysis. This is usually earlier than seems apparent to us. Nandita Shah suggested that the case is often complete within the first 5 minutes; the remainder of the interview is for confirmation. While this may be hyperbole, it embodies an important truth; that the limiting process in our work is our ability to recognize the disharmony of the patient out of the mass of puzzle-pieces we've accumulated; which often requires that the patient display this disharmony before us in myriad ways before we finally catch on.

There will still be places of apparent incompleteness. We may still have prompts for modalities in the margins of our notes that have gone unfilled - either because the questions resulted in other answers, or because the 90 minutes we've reserved has sped by without the chance to ask. While we might look at these prompts longingly, it is important to realize that a fourth leg does not add additional stability to a three-legged stool; what the patient has shared in the interview is what we are privileged to work with. Recall the story of the loquacious lady with the stretched-out turtleneck.

Reflect on Hahnemann's Aphorism 104:

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.

Thank the patient, arrange followup for the prescribing visit based on urgency and time needed for adequate study of the case, and prepare to move on to the next step in homeopathic practice ...

But that's for next month.

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