The consequences of those guidelines

When I look around the profession I see profound consequences from these guidelines. We are pushing in the opposite direction to patients. What do they want?  What do we want them to do?  What are their values and attitudes towards health? Cure? How long do they want their treatment to last? Just what is their attitude towards maintenance of their health? You can be sure that only 10% of the population has the same values as you do when it comes to that. And yet so often when the homeopath talks and prescribes to our patients we are assuming that they’re just like us. And when they then don’t comply we label them as ‘difficult patients’ or ‘non compliant patients.’

Many homoeopaths are struggling. Many homoeopaths don’t see enough clients. Of course there are multiple reasons but one of them is of our false expectations of what our patients are actually looking for. They have different values and different assumptions about themselves and their health. And we find ourselves in the awkward situation of prescribing in the 21st century for 21st century patients, patients that have been bought up on U-tube and Facebook and PDA’s  and food colouring and fluorescent lights and the pill, when the basic paradigms of our profession are rooted firmly in the 18th and 19th centuries. Old paradigm, new world. We are even trying to sell the word ‘homoeopathy’ in the 21st-century marketplace. It’s a very big ask.

It is the opinion of this author that the consequences of such fixed guidelines by Close, Kent and Vithoulkas etc, and such rigid ideas that are so clearly out of step with our patients realities go a considerable way to reducing clinical efficacy, and creating a climate of fear, hesitancy and anxiety amongst homeopaths, and especially recently graduated homeopaths work. There is a very poor conversion rate to successful practice in the profession, a lack of confidence in prescribing, and at times poor satisfaction rates with our clients. There is also hesitancy to publish clinical results for fear of being beaten by the homeopathic police. To enforce the point, in exhaustive searching in the homeopathic literature, the only reference found where a contemporary authoritative homeopath made reference to integrative treatment was in Morrison. (1998).

Management. Many of our patients are already seeing a body worker or physician (chiropractor, osteopath) when they begin homeopathic treatment. Also, these health professionals often refer to us in an attempt to keep their patients away from the risks of allopathic medications or surgery. Startlingly, some homeopaths, out of fear of antidoting, ask such referred patients to refrain from seeing their referring practitioner. Needless to say, this practice is divisive in the alternative community and does more harm than good. Instead we must work with our alternative colleagues and discuss our concerns rather than put our patients in a position of divided loyalty.

Research the modern academic literature for guidelines

Looking into any academic homeopathic literature to give direction on this area of clinical practice proved fruitless. There is very little if any knowledge base. Moreover it is very difficult to search the literature. Researching the subject was time consuming and exhausting.[6] There were certainly many examples of research into the effectiveness of homeopathy in relationship to Integrative Medicine.[7] There is much research on the integration of some homeopathic training into existing orthodox medical curriculums.[8] Furthermore there is demonstrable research of homeopathy integrating into the existing curriculums of CAM therapies.[9] But nothing on how to integrate.

Researching laterally when inputting search terms proved no more fruitful. One researcher flew to New Zealand to search in the only partially electronic Julian Winston archive. Only one article on homeopathy was found that mentioned integrative treatment. Simillimum (2005) contained an article by Amy Rothenberg who documented the use of Arsenicum and other naturopathic interventions. After conducting an extensive search of relevant literature this was the only real example of an article or research which demonstrated homeopaths attitudes to patients’ use of other complementary and alternative medicine or conventional medicine alongside homeopathic treatment.  What has been interesting to note is that in most reported cases in homeopathic journals, the homeopaths refer to the remedies and the homeopathic treatment given to their patients, but very rarely document any other modes of treatment that patients may be using concurrently, which may have an effect on the progression of their health problem.

However what was discovered were studies on how other health professionals felt about patients choosing other healthcare regimes. Giveon, Liberman, Klang & Kahan (2003) surveyed 150 doctor’s perceptions of their patient’s use of complementary medicine concluded that 91% of the respondents were ‘satisfied’ or ‘not bothered’ about their patients’ use of complementary medicines.[10] Furthermore, Nanke and Canter (1991) conducted another survey which examined doctor’s recommendations of other forms of treatment to their patients.[11] And confirmation that patients are more than happy to mix modalities came in Sharples, Van Haselen & Fisher (2003) survey of United Kingdom NHS patients’ perspectives on Complementary Medicine where four hundred and ninety nine responses were analysed.  The patients were all receiving treatment at the Royal London Homeopathic Hospital. Their most frequent reasons for seeking CAM intervention were that other treatment had not helped, and the concerns that they had about adverse treatment reactions which may occur when using conventional medicine. The most frequently used complementary therapy was homeopathy and two thirds of the patients surveyed indicated that their main presenting condition was moderately or much improved.[12]

Results of searching in the literature of other CAM disciplines.

Searching outside of the world homeopathic medicine into other complementary therapies to determine their attitudes to multiple interventions was undertaken. Interviews and audits, electronic based research of practitioners in other CAM therapies, and exploration of their curriculums and directives to determine their attitudes to patients seeking multiple modality treatments were conducted.

Over the years I found it incredibly valuable to work alongside naturopaths and practitioners of traditional Chinese medicine, Ayuvedic medicine and all the other complementary and alternative medicines in the different clinics that I worked and around Sydney and Auckland. From discussions about multiple interventions they didn’t seem to care so much that their patients have their own initiatives and values about their health, and they don’t get upset about it. And actually it doesn’t worry them in TCM if their patient is also seeing a homoeopath. They are less precious, and they are less concerned.

In formal interviews, what was asked was how they deal with patients getting multiple modality treatments; what instruction do they get in their training; do they get as angry with patients and other practitioners as homeopaths do; do they have any further ideas and research; do they worry as much revealed a clear pattern? Research focused especially on TCM practitioners who were homeopaths as well and who were familiar with it or used homeopathy. One said,

‘There is not the dogma in TCM around repetition of the dose so much. It is much more relaxed. We give herbs to be taken every day. There are some clear contraindications at times – say a patient is on blood thinners and other treatments but over all we are less precious. Other therapies are welcomed like sports medicine, bodywork is welcomed. TCM is often practiced with the practitioner doing herbs needles and bodywork anyway.’

When asked about the Direction of Cure the response was, ‘All other therapies are seen as helping not hurting’ (Interview T12). Nevertheless, as in Homeopathy, students of TCM colleges in the US and Australia reported no curriculum time being devoted to this. They also reported surprise that it would even be an issue (Interview T11 and T12).

Reconstruction and Development; Next steps in developing this area of practice.

There are many proposals in developing this area and a lot of work to do.

Communication. It is crucial that as a profession we have more dialogue, robust discussion and debate. And as we do so we also need to realise that one homoeopath who practices in a specific way because of their training, because of their perception of health and disease and their concept of totality may be legitimately different to the homoeopath practising in Ipswich, Wagga, Adelaide or where-ever. Our practices are different and varied and our working models need to reflect this. There is much that is different but significantly more that a similar.

Audit tools. Consistent use of an audit tool that is agreed upon would go a huge way to creating statistical facts about our clinical effectiveness. For example, one audit tool which could be employed more would be to categorise patient response.

• No change
• Some improvement
• Considerable improvement
• Major change
• Transformation

Percentages can be used or a different and agreed-upon language, slight, some, significant improvement etc. Homeopaths must be encouraged to engage in this necessary critical reflection.

Audit tools that reflect multiple interventions. Results can be cross referenced with the treatments and modalities being used at the same time as homeopathic treatment.

• Just homeopathy
• Homeopathy and one modality
• Homeopathy and multiple modalities

Already the computer software packages contain the capacity for significant statistical analysis of practice. Who uses them? We need to. In the absence of being able to describe how homeopathy works – the mechanism of action, we must be in a position to provide evidence of our clinical efficacy.

Research. Much more research is necessary. The deconstruction and then reconstruction and collection of information from clinical practice is deeply satisfying. But beyond understanding exactly what goes on within one’s practice, and having some prejudices and ideas challenged about different aspects of that practice at a personal level, combination with similar audits from multiple practitioners can provide clear demonstrative research of the type that is required to demonstrate a clinical efficacy in the modern marketplace.  It is not difficult.  It’s not hard.  You don’t have to have a PhD in statistics to do it.  You just have to do it. From conducting such audits on a regular basis I know exactly the demographic of my practice.  I know exactly the percentage of patients I see once, and a breakdown of male and female that I see once. I know exactly how many patients I seek twice or seven times or 22 times. I know exactly how many remedies are prescribed to each patient on average. I know exactly how many times I use Scholten method successfully, or Sankaran, or Boenninghausen, or how many times I use multiple methods in my clinic. Rather than guesswork I now know about the compliance of my patients and their improvement after the first consultation, and at the end of the treatment.

Criteria for cure and publication. It is crucial that as a profession we have a dialogue and then establish ourselves some fundamental agreement on what can be considered a curative or publishable case. To my mind that definition of ‘cure’, or ‘improvement’ needs to include the celebration of patients that are getting other therapies and doing other things with their health, or at the very least a criteria for reporting cases which is more real-life. It is clear from substantial reading that reported cured cases in homeopathy are overwhelmingly where one remedy was used and where no other treatments were had or reported. The clear reason for this is to determine that nothing else medicinal was going on in the health of the patient or any other treatments that this remedy created that change, i.e. this created that. But this is out of step with reality by not acknowledging the very real improvement in some cases partially due to the Therapeutic Relationship and other medical interventions. It is confusing for all that homeopaths are encouraged to report ‘cured cases’ yet such cases are dismissed when the peers and readers see that the patient was also getting Chinese medicine or flower essences or steroid creams (Interview H10-17). There needs to be more freedom in publishing cures and cases that reflect our actual clinical experience. Another excellent attempt by Thompson (2004) has been made at a model for a ‘Formal Case Study’ in Can the Caged Bird Sing.

Education. Many of our educational assumptions need to be re-examined in the curriculums in colleges. A reemphasis to an honest discussion of homeopathy’s place in the perception of the patient and the context of CAM is in order in most curriculums. Substantial anecdotal evidence suggests that homeopathic students leave college’s world wide high on skills and low in confidence. While crucial to grasp the fundamentals of the minimum dose and the direction of cure, it is doubly important in clinical training that these concepts need to be grounded in the real world of patients expectations. This aspect of practice needs to be developed, and integrated in to the working curriculum of every college, and the daily practice of every homeopath.

Furthermore, strongly emphasising Hahnemann’s actual classification of disease is in order. It is often forgotten that Hahnemann classified Chronic Disease. Homeopaths often assume this was his idea of Psora, Sycosis and Syphilis. In fact he had a broader classification which included :-

Pseudo Chronic Disease, Artificial Chronic Disease and True Chronic Disease. Being reminded of this reality often creates a context for homeopaths to see the genuine role of naturopathic interventions and lifestyle advice (for the results of pseudo chronic and artificial disease).

What is also needed is the development of clear clinical guidelines and rules and the building up of literature for complicated cases and complicated clinical situations. Many lecturers make assertions but upon a flimsy evidence base.

The development of clear clinical guidelines. To my mind it is crucial that we establish some firm literature through argument and disagreement, through audit and literature reviews in relation to patients that are living 21st-century lifestyles and who have in their cases many obstacles to cure and maintaining causes and who are ‘behaving badly.’ The development of clear clinical guidelines and ideas around best practice does not necessarily have to restrict us in what we do. Clinical guidelines are not necessarily ‘this remedy for that condition.’  But models of working and guidelines and directions that are underpinned by evidence have significantly helped other similar professions develop and grow.  One only needs to glance at the developments in nursing, physiotherapy, and psychotherapy in the last 20 years to see how they have outstripped and outperformed homoeopathy in the area of research, and ultimately medical respectability.

Conclusion

After exhaustive searching and research it is concluded that there is very little if any literature or guidance when it comes to this genuine clinical issue of patients seeking multi modalities or multiple treatments. There is very little or no knowledge base underpinning these questions. There is plenty of real life clinical experience. But while clinical experience counts for a lot, evidence is often perceived as more valuable.

Having deconstructed the knowledge base, critically analysed, reviewed and reflected, on the traditional homeopathic literature it is clear that much of it is out of step with patients’ perceptions of CAM. Furthermore the dearth of any academic literature on this issue highlights the need to develop this area of practice.

Are our patients behaving badly? No they are just doing what they do. It’s homeopaths expectations which are fixed and need to change or at the very least some additions need to be made to clinical frameworks. None of the practitioners interviewed from other disciplines had the preciousness or the tightness around their patients having other modalities’ treatments that homeopaths did. Perhaps concepts of suppression and ideas of spoiling the case (Close Kent and others) impedes practice. Therefore it is proposed that the steps suggested, research, rethinking the publication of cured cases, a reorientation of the emphasis within undergraduate curriculums and the development of some literature around clinical skills in multi modality cases, are implemented to use as a springboard by which the profession can move forward.

References

von Ammon, K & Thurneysen, A 2005, Homeopathy incorporated in a Swiss university – aims and results of 10 years, http://www.thieme-connect.com/ejournals/abstract/ahz/doi/10.1055/s-2005-868674. [Accessed: July 2008].

Chez, R &  Jonas, W 1997, The challenge of complementary and alternative medicine. Primary Care. American Journal of Obstetrics & Gynecology. 177(5):1156-1161, November 1997.

http://pt.wkhealth.com/pt/re/ajog/abstract.00000447-199711000-00033.htm;jsessionid=FvTGzv9FQY2q93T7FJfvhHrQgYMT4lr2ZkGFWQd1Rl2h1TSv2TbF!-1480123504!-949856144!8091!-1.[Accessed: July 2008].

Close, S 1921, Genius of Homeopathy Lectures and Essence of Homeopathic Philosophy. Reprint. India. Jain.

Gaudet, T 1998, Integrative Medicine, the Evolution of a New Approach to Medicine and Medical Education. http://scholar.google.com/scholar?hl=en&q=%27integrative+medicine+homeopathy%27+&spell=1. [Accessed: July 2008].

Giveon, S et al (2003, A Survey of Primary Care Physicians’ Perceptions of their Patients’ Use of Complementary Medicine Complementary Therapies in Medicine (11) pp.254-260.

Gray, B 2000, Interferences- Antidotes. Available at  http://www.billgrayhomeopathy.com/Interferences.html [Accessed: July 2008].

Hahnemann, S 1997, Organon of Medicine 5^th & 6^th eds. http://www.homeopathyhome.com/reference/organon/organon.html [Accessed: July 2008].

Hamilton, E 2003, Exploring General Practitioners’ attitudes to homeopathy in Dumfries and Galloway. Homeopathy, Volume 92, Issue 4, October 2003, Pages 190-194. Science Direct   [Accessed: July 2008].

Hargreaves, A 1994, Changing Teachers, Changing Times. London: Continuum.

Harris, P et al 2003, Complementary and Alternative Medicine Use by Patients with Cancer in Wales: a cross sectional survey Complementary Therapies in Medicine (11) pp.249-253.

Harris, P & Rees, R 2000, The Prevalence of Complementary and Alternative Medicine Use among the General Population: a Systematic Review of the Literature Complementary Therapies in Medicine (8) pp.88-96.

Johnston, L, Constitutional Homeopathic Treatment – Antidote List, http://www.homeopathy-md.com/Homeopathy_/Patient_Info/Antidote_List/antidote_list.htmlgroup, [Accessed: July 2008].

Kristof, O et al 1998, Patterns of use and attitudes of Complementary Medicine Consumers in Switzerland Complementary Therapies in Medicine (6) pp. 25-29.

Mangliavori. M &  Zwemke, H 2004, Bitten in the Soul Experiences with Spider Remedies and Homeopathy. Moderna and Berlin.

Morrison, R 1998, Desktop Companion to Physical Pathology. San Francisco. Hahnemann Clinic Publishing.

Nanke, L & Canter, D 1991, Treatment Recommendation in Complementary Medicine: a selective network Complementary Medical Research Vol. 5 (1) pp.1-7.

Riley D et al 2001, Homeopathy and Conventional Medicine: An Outcomes Study Comparing Effectiveness in a Primary Care Setting. The Journal of Alternative and Complementary Medicine. Apr 2001, Vol. 7, No. 2 149 -159. www.liebertonline.com/doi/abs/10.1089/107555301750164226 last accessed March 2007. [Accessed: July 2008]

Rogers, CR 1951, Client-Centred Therapy. Boston: Houghton Mifflin.

Rotherberg, A 2005, A  Case of Interstitial Cystitis. Simillimum Volume XVIII Spring/Summer.

Sharples, F & Van Haselen, R & Fisher, P 2003, NHS Patients’ Perspective on Complementary Medicine: a survey Complementary Therapies in Medicine (11) pp 243-248.

Thompson, T 2004, Can the Caged Bird Sing Reflections on the Application of Qualitative Research Methods to Case Study Design in Homeopathic Medicine. BMS Medical Research Methodology. 4.4.

Tuckman, B & Jensen, M 1977, Stages of Small Group Development Revisited Group and Organisational Studies (2) pp 419-427.

Vithoulkas, G 1986, The Science of Homoeopathy Northamptonshire: Thorsons Publishing Group, p 263.

Wyllie, M & Hannaford P 1998, Attitudes to complementary therapies and referral for homeopathic treatment: A survey of general practitioners in Lothian, Scotland. Homeopathy, Volume 87, Issue 1, January 1998, pp 13-16.

Appendices

Interviews Conducted

H10-17

H15 – 7

T11 -  -

T12 -  -

H13 – 25

H14 – 25

N16 – 8

N18 – 11

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[1] Alastair Gray, Marianne Roman, Jacqueline Dodding Clinical Audits 2007.

[2] One researcher did a complete clinical audit of all cases over the last 4 years. Other researchers did an audit of their own practices, looking at many cases that been unsuccessful, cases where patients ‘behaving badly’ had influenced what was done and had an impact on the outcome. Cases were examined where there were many integrative techniques. Cases were examined where other practitioners had prescribed or intervened during the patient’s homeopathic treatment.

[3] What is presented here is 10% of that audit; a micro audit of clinical practice. Of the random 55 cases produced of the 550 here 4 had no other treatments, representing 7%, in other words 93 % of patients are receiving multi modalities or multi treatments.

[4] Patient previously had homeopathy in Pakistan

[5] This is obviously just one practitioner’s results from an individual clinic. The clinic is inner city Sydney. Clientele overwhelmingly educated, western, aspirational. Anecdotal evidence from colleague’s world wide suggests a similar trend in the western world. The exception was a conversation with Andreas Bjorndhal (Norway)  who said it is extremely rare to have patients in his practice on other treatments.

[6] Explored were many databases, the UCLan library, Google, Google Scholar, EBSCO, INFORMIT, MICROMEDEX, PROQUEST, Science Direct, then journals such as British Medical Journal, American Medical Association, Complementary Medical Research Journal, British Homeopathic Journal, Society of Homeopaths Journal, Simillimum, NASH, NESH and much more.  Initially starting with integrative medicine in various relationships with homeopathy, then integrative medicine, homeopath’s attitudes, and other combinations of words, there were many dead ends. This was doubly the case when combined with searching the other therapies that can be combined with homeopathy. Very little information was discovered which was relevant to the initial question posed.

[7] Example. The Journal of Alternative and Complementary Medicine. Homeopathy and Conventional Medicine: An Outcomes Study Comparing Effectiveness in a Primary Care Setting. Apr 2001, Vol. 7, No. 2 : 149 -159. David Riley, MD. University of New Mexico Medical School, Albuquerque, New Mexico; Integrative Medicine Institute, Santa Fe, New Mexico. Michael Fischer, PhD. ClinResearch, Cologne, Germany. Betsy Singh, PhD. Southern California University of the Health Sciences, Whittier, California. Max Haidvogl, UD, DrMed Ludwig-Boltzmann Institute, Graz, Austria. Marianne Heger, MD. Research Center HomInt, Karlsruhe, Germany. Background: Recent meta-analyses of randomized controlled trials in homeopathy have suggested that homeopathy is more than a placebo response. Objective: Comparison of the effectiveness of homeopathy in primary care with conventional medicine in primary care for three commonly encountered clinical conditions. Results: Four hundred and fifty-six (456) patient visits were compared: 281 received homeopathy, 175 received conventional medicine. The response to treatment as measured by the primary outcomes criterion for patients receiving homeopathy was 82.6%, for conventional medicine it was 68%. Improvement in less than 1 day and in 1 to 3 days was noted in 67.3% of the group receiving homeopathy and in 56.6% of those receiving conventional medicine. The adverse events for those treated with conventional medicine was 22.3% versus 7.8% for those treated with homeopathy. Seventy-nine percent (79.0%) of patients treated with homeopathy were very satisfied and 65.1% of patients treated with conventional medicine were very satisfied. In both treatment groups 60% of cases had consultations lasting between 5 and 15 minutes. Conclusions: Homeopathy appeared to be at least as effective as conventional medical care in the treatment of patients with the three conditions studied. http://www.liebertonline.com/doi/abs/10.1089/107555301750164226.

[8] Example. Integrative Medical Education: Development and Implementation of a Comprehensive Curriculum at the

University of Arizona. Victoria Maizes, MD, Craig Schneider, MD, Iris Bell, MD, PhD, MD(H), and Andrew Weil, MD

http://scholar.google.com/scholar?hl=en&q=%27integrative+medicine+homeopathy%27+&spell=1, or, The challenge of complementary and alternative medicine. American Journal of Obstetrics & Gynecology. 177(5):1156-1161, November 1997. Chez, Ronald A. MD; Jonas, Wayne B. MD http://pt.wkhealth.com/pt/re/ajog/abstract.00000447-199711000-00033.htm;jsessionid=FvTGzv9FQY2q93T7FJfvhHrQgYMT4lr2ZkGFWQd1Rl2h1TSv2TbF!-1480123504!-949856144!8091!-1, or Homeopathy incorporated in a Swiss university – aims and results of 10 years „KIKOM” Integration der Homoeopathie an einer Schweizer Universität – Ziele und Resultate von 10 Jahren „KIKOM” K von Ammon¹, A Thurneysen¹ Institute of Complementary Medicine KIKOM, University of Berne, Inselspital, Bern, Switzerland. http://www.thieme-connect.com/ejournals/abstract/ahz/doi/10.1055/s-2005-868674.

[9] Example. Status of Complementary and Alternative Medicine in the Osteopathic Medical School Curriculum. Dale W. Saxon, PhD; Godfrey Tunnicliff, PhD; James J. Brokaw, PhD, MPH; Beat U. Raess, PhD. The authors found that CAM material was usually presented in required courses sponsored by clinical departments, was most likely taught in the first 2 years of medical school, and involved fewer than 20 contact hours of instruction. The topics most often taught were acupuncture (68%), herbs and botanicals (68%), spirituality (56%), dietary therapy (52%), and homeopathy (48%). Most (72%) CAM instructors were also practitioners of CAM modes of therapy. Few (12%) of the instructors taught CAM from an evidence-based perspective. The authors conclude that the form and content of CAM instruction at osteopathic medical schools is similar to that offered at allopathic medical schools and that both osteopathic and allopathic medical schools should strive to teach CAM with less advocacy and more reliance on evidence-based medicine. http://www.jaoa.org/cgi/content/abstract/104/3/121.

[10] Although the survey was directed more to the use of herbal remedies rather than homeopathy, this is still a useful indicator of other health professional’s responses to clients using other forms of medicine alongside their own.  Of note however is that 58% of the physicians who responded to the survey routinely asked patients whether they were using other forms of medicine concurrently with their own.

[11] The results of the survey showed that core treatment methods such as counselling, diet, exercise and massage, and well-established complementary and orthodox treatments such as osteopathy, acupuncture, orthodox medication, homeopathy, herbal medicine and psychotherapy were the most widely recommended.  In contrast those treatments described as ‘fringe’ treatments (e.g. radionics, biofeedback, colour therapy, gem therapy, Kirlian aura diagnosis) were the least recommended.

[12] 19.5% reported that it was slightly improved, 13.5% reported no change, 2% were slightly worse and 3% were moderately or much worse.  The survey also requested information about other treatments that patients were also receiving as well as the treatment from the RLHH.  Half of the patients were receiving treatment other than that prescribed at RLHH.  Just under a third were taking conventional prescription medicines, 13% treatment from another hospital doctor, 12% non-prescription medicines, and 7% were using complementary therapies from elsewhere.  Therefore, once again, this survey has demonstrated that patients often choose to use more than one therapy concurrently, whether it is complementary or conventional.  Although two thirds of the patients reported that their main presenting complaint had improved either moderately or significantly, it is difficult to establish whether the main therapy has caused the moderate or significant change in the patient’s health.