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| Hpathy Ezine - April, 2009 | ||||
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Abstract Introduction: The study reviews the use of prognosis in homeopathy, the difference between conventional medicine and homeopathy in assessing the prognosis, and evaluates various factors contributing to the assessment of prognosis in Homeopathy. Methods: A literature review was used to determine available evidence of use of prognosis in homeopathy and to determine the factors contributing to assessment of prognosis in homeopathy. Results: The review of conventional medicine literature suggests that most patients want to know about their prognosis but doctors are often unable to give an accurate prognosis. Most conventional research in prognosis relates to the prognosis of specific diseases. The review of homeopathic literature did not bring up any systematic research or study related to prognosis. Homeopaths rely on factors like vital force, miasms, extent and duration of pathology, and remedy-response to assess the prognosis of a case. The focus is usually on deciding the prognosis of an individual patient and there is insufficient data available regarding the prognosis of specific disease conditions in homeopathy. Conclusion: If efficacy of homeopathy in various diseases is assessed statistically and such data is then coupled with the individualizing factors of a case, homeopaths might be able to offer better prognosis to their patients. Keywords: Prognosis, Homeopathy, Remedy-response.
Introduction The word ‘prognosis’ comes from the Greek prognostikos (of knowledge beforehand). It combines pro (before) and gnosis (a knowing) (MedTerms, 2008). Medical prognosis is an estimate of cure, complication, recurrence of disease, level of function, length of stay in health care facilities, or survival for a patient or group of patients (Leondes, 2003). According to Christakis (1999), prognostication is a sensitively delivered and well-calibrated best guess about the patient’s future. Apart from helping medical practitioners in predicting the course of disease and result of a treatment, prognosis information can help medical researchers to identify patterns of disease evolution. It can assist people of health care sector in predicting the needs of their served populations and, consequently, allocate resources accordingly. It can also serve as an additional aid for patients to understand and make informed decisions about their conditions. It has been documented that most patients want to be informed about their prognosis (Kaplowitz et al, 2002), but studies have shown that physicians are usually not accurate when formulating prognoses (Christakis, 1999). For example, in a classic study, Parkes (1972) noted that physicians were systematically biased in their predictions, tending to overestimate how long patients had to live. Another study confirmed this, showing that fewer than 20% of physicians' predictions are accurate and that survival is typically overestimated 5-fold (Christakis & Lamont, 2000). Research done by Christakis and Ivashyna (1998) suggests that physicians disdain prognostication: 60.4% find it "stressful" to make predictions; 58.7% find it "difficult"; 43.7% wait to be asked by a patient before offering predictions; 89.9% believe they should avoid being too specific; and 56.8% report inadequate training in prognostication. Prognosis in Homeopathy Patients who come to Homeopaths often ask questions like – ‘Is it curable?’, ‘How long will it last?’, ‘For how long do I need to take the remedy?’, ‘What will happen after you give me a homeopathic remedy?’ etc. (Royal?) While homeopathic literature mentions the word ‘prognosis’ and the factors used to assess the curability of a case, there seems to be no systematic effort to measure and document the accuracy of a homeopathic prognosis. The review looks into the available literature to find out how homeopaths prognosticate. Methods Literature Research An extensive review of contemporary and historical homeopathic literature was carried out using electronic databases (Encyclopedia Homeopathica 2006, Hompath Tresoire 2000, Pubmed) for the following search terms: Prognosis, Homeopathic Prognosis, Homeopathy Prognosis, Remedy reaction, Remedy response, Kent’s observations, Curability. Moreover published material in journals such as LINKS, Homeopathy, The Homeopath and The European Journal of Classical Homeopathy was searched to find references to the term ‘prognosis’. An extensive review of the conventional medicine literature was also carried out through PubMed and online access to various journals like British Medical Journal, Journal of Clinical Oncology, and Archives of Internal Medicine etc., accessible as electronic databases through Athens login. Results The research into the conventional medicine literature brought forth some interesting findings like:
(Christakis 1999; Christakis & Ivashyna 1998; Christakis & Lamont 2000; Christakis & Sachs 1996 ) This brings up an interesting dilemma – while patients need information about their prognosis, doctors either do not like to give a prognosis or are unable to give an accurate prognosis. The prognostic accuracy can be as low as 20%. The review of conventional medicine literature (PubMed) also showed that most of the research done on prognosis was in relation to specific diseases and their relation to specific physiological, pathological and biochemical variables of the disease. There were no general studies about assessing the prognosis of the ‘patient’. A conventional doctor can only prognosticate if he is aware of the research done about the individual disease. The research into homeopathic literature did not bring up any research, review, or systematic study related to the use of prognosis in Homeopathy. There appears to be little or no evidence base for the systematic study or use of prognosis in homeopathy. The factors that help in defining a prognosis for a given case are often mentioned separately in literature and a consolidated overview to this subject is not available. Many instances of the word ‘prognosis’ were found in homeopathic literature, however mainly in reference to the conventional use of the term. Contemporary authors also use the term prognosis, though sparsely and without consistency. Published case reports rarely refer to the term prognosis. Most of the references found were in relation to remedy-reaction (medicinal aggravation, homeopathic aggravation and other reactions suggested in Kent’s 12 observations (Adler et al. 2006, Amberger 2005, Kent 1954), vital force and miasms. The following factors were found mentioned in homeopathic literature, in relation to the prognosis and curability of a case/patient:
Some of these factors are discussed hereunder: Individuality of the Case Homeopaths believe in the adage: ‘Don’t treat the disease, treat the person who has the disease’ (Schepper, 1995). Homeopaths are often taught that the name of the disease does not matter much. It is the individuality of the case that matters. (Schepper 1995, 1999) The individuality is derived in part by finding what is characteristic about a particular patient. While conventional medicine focuses on common factors in patients with a particular disease to give a prognosis, homeopaths rely on ‘what differentiates this person from all the others suffering from the same disease?’ Homeopaths believe that if they are able to find characteristic information in a case, the prognosis is much better. The characteristic (peculiar) information may not be related to the disease itself, it could be a causative modality, a general modality, some concomitant symptoms, or mental and emotional symptoms/traits, or a combination of these. (Saine 1991, Schepper 1995, Kent 1954, Roberts 1942, Vithoulkas 1980 and others) Strength of the Vital Force Homeopaths believe that a person with strong vital force gives a better response to the suitable remedy and is much easier to cure (Saine, 1991). Even if the patient is suffering from grave pathology, the chances of cure depend upon the strength of the vital force. It is believed that a similar homeopathic remedy elicits a curative reaction from the vital force. If the vital force is very weak, it does not respond properly to a similar stimulus and the chances of cure are less. (Kent 1954, Little n.d., Roberts 1942, Schepper 1995, Vithoulkas 2000 ) Underlying Miasm Homeopaths classify most diseases under the three miasms Psora, Syphilis and Sycosis (Hahnemann 1838, Vijayakar 1998). While each miasm can cover a multitude of pathologies, in simplistic terms, homeopaths believe that Psora causes functional changes, Sycosis related to growth (under- or over-) changes and Syphilis relates to degenerative or destructive changes. (Kent, 1954) It is believed that the miasm Syphilis is more grave than Sycosis and the miasm Sycosis in turn is more grave than Psora. (Allen 2003, Banerjee 1931, Ortega 1980, Roberts 1942, Vijayakar 1998) Accordingly, it is believed that the less harmful the underlying miasm, the easier it is to bring about a cure. Extent & Duration of Pathology Homeopaths also rely on the extent and severity of the pathological changes to give a prognosis and to ascertain the curability of a case. Homeopathy relies on body’s own defense mechanism and healing abilities to bring about a cure. If the pathological changes are so advanced that the body cannot reverse them, the homeopathic remedy may not be able to bring about a cure and only a palliative response may be possible. (Kent 1954, Roberts 1942) If there are no structural changes, prognosis is considered good (Weir n.d., Saine 1991). Sudden acute onset of a condition makes the prognosis grave (Boger 1929). Diseases of very long duration are considered to have an unfavorable prognosis (Shore 1998, Vithoulkas (2000). Disease Diagnosis While homeopaths are taught that the name of the disease does not matter much, homeopaths seem to consider disease diagnosis important for prognosis (Tyler n.d.). The texts (e.g., Burnett 2004, Borland 1939, Norton 1882) dealing with clinical application of remedies or therapeutics often mention the prognosis in terms of conventional diagnosis. Similarity of the Remedy Chosen Homeopathy depends on the application of the law of simila (like cures like) to cure a patient. It is believed that the more similar the remedy to the patient’s condition, better is the curative response elicited (Close 1924, Kent 1954). A ‘simillimum’ is able to restore health in the most gentle and quick manner. If a remedy has to work curatively, it needs to be as similar as possible. A partially similar remedy only elicits a palliative response or may need different medicines to complete the cure (Sherr, 2007). Past Medical History, Treatment and Suppression If the patient has a long medical history, complaints present since birth or has taken lots of suppressive treatment, prognosis is not considered to be good. (Shore 1990, 1991, Saine 1991) Family History If there is a family history of chronic and incurable diseases like Schizophrenia, Cancer, Tuberculosis etc, the prognosis is not considered good. (Shore 1990, 1991) Remedy Response Homeopaths often use the response of the patient after a remedy is administered, to decide the curability or the prognosis of a case. Kent (1954) noticed twelve different remedy reactions. A short aggravation of presenting complaints followed by lasting amelioration is considered a good prognostic indicator. Likewise, appearance of old symptoms (Vijayakar, 2008), a discharge, or sound sleep (Baehr 1870, Winston 2001), an acute (Sherr, 2007), movement of symptoms from within-out, from above-downwards and from more important to less important organ (Kent 1987, Vijayakar 1998) are all considered indicators of a curative response and a good prognosis. Vijayakar (1998) also considers that change in the miasm of the patient from Syphilis to Sycosis to Psora is a good prognostic indicator. Case Management The selection of the most similar remedy is not always possible and single remedy cures are not very frequent (Sherr, 2007). Homeopaths believe that if the remedy is not similar or if the case has many layers or if the underlying miasm needs to be addressed separately, then more than one medicine may be needed in a case (Ghegas, 1999). Even if the right remedy is selected in the first instance, it requires good case management to cure a chronic case of many years’ duration (Sherr, 2007). The case management includes evaluation of remedy response, decisions about subsequent prescriptions, potency selection, repetition etc. It is believed that the result in a case not only depends upon the remedy selection but also the case management (Little n.d., Schepper 1995, 1999). Discussion Prognosis in Homeopathy The concept of health, disease and cure in homeopathy is very different from the views held by conventional medicine (Schepper, 1999). Homeopaths work on the basis that the human body is one integral whole, which falls sick as a unit and not in parts. Homeopaths also believe that there is a life force, called the Vital Force, which animates the human body and is responsible for all life functions (Hahnemann, 1921). The concept is similar to the concept of Prana in Ayurveda and Chi in TCM (Schepper, 1999). It is believed that a person becomes sick only when his/her vital force is deranged or weakened (Hahnemann, 1921). There is also a difference in assessing the progress of case from a homeopathic point-of-view. Homeopaths believe that even if the physical complaints worsen but the patient is feeling mentally better or his energy levels are improved, the prognosis of a case is good (Boger 1929, Hahnemann 1921, Kent 1954, Roberts 1942, Vithoulkas 2000, Weir n.d.). Similarly, if after giving a homeopathic remedy, there is recurrence of a complaint that the patient has suffered in the past, the prognosis is considered to be good (Kent 1954, Vithoulkas 2000, Weir n.d.). Such concepts are unique to homeopathy and are not found in conventional medicine. Conventional prognosis is more clearly defined but cannot be directly transferred to homeopathic prognosis due to philosophical and practical differences. Due to these fundamental differences in its approach, the concept of prognosis as held by homeopaths is different from the conventional medical prognosis. The homeopathic prognosis in individual cases can be strengthened by the knowledge of the relative efficacy of homeopathic medicines in various pathological conditions. Many studies have been done to assess the efficacy of homeopathic remedies in clinical conditions like Hay fever, Asthma, ADHD, Depression, Menstrual disorders etc (ENHR, 2005). But compared to the research available in conventional medicine, this data is miniscule. I feel that if a large number of clinical trials were conducted for assessing the efficacy of homeopathy in various pathological conditions, homeopaths would be able to provide a defined application of prognosis that is not only true to homeopathy philosophy, but is also grounded in hard facts. Other factors that may affect prognosis There are many other factors that come into play during a homeopathic consultation and affect the outcome of a case. These include the personal skills of a homeopath (Boger 1929, Kent 1954, Saine 1991), the method (classical, polypharmacy or complex homeopathy) being used, the choice of potency, case management, the relationship between the homeopath and the patient, the depth of case-taking (can elicit placebo response)(Sarah et al. 2004), the belief of the patient, the quality of the medicines, decision and justification processes (Brien et al. 2004, Milogram 2004, Wansbrough 2005) etc. In homeopathic terms, prognosis often deals with assessing what will happen after a remedy is given. But unlike the conventional medicine, the process of selecting and giving the remedy is not standardized in homeopathy because of the factors mentioned above. Methods to improve the understanding of homeopathic prognosis. The following methods can be used to improve our understanding of prognosis in relation to individual patients:
Peer review from published articles, arguing the importance of prognosis as well as suggesting a definition of the term would be of value to peers. The need for some standards have been expressed at the ECH meeting in 1997 and put out for peer review by Steinsbekk and Brands in 1998, but apparently without further results. Conclusion The prognosis of an individual patient depends not only on the pathology and disease but also on variety of other factors like age, gender, life-style, diet, available patient care, social and cultural background, general strength of the patient, and mental attitude towards sickness. Conventional medicine focuses primarily on diagnosis and therapeutic intervention, and often fails to give an individualized prognosis to a patient. The prognosis offered by conventional medicine usually deals with projecting the future course of a disease with or without the application of known therapeutic interventions. Inspite of the large number of studies on prognosis in conventional medicine, physicians are often unable to give an accurate prognosis. This indicates that evaluating the prognosis of a ‘patient’ by projecting the prognosis of a ‘disease’, usually does not give accurate results. During the process of homeopathic treatment, the result is heavily dependent on the homeopath’s evaluation and understanding of the case. Considering the subjectivity in these evaluations, a standard prognosis only related to the name of the disease and level of pathology may not be possible in homeopathy. At present, there are few good studies available on the relative efficacy of homeopathic medicines in various disease conditions (ENHR 2007). Therefore it is not possible to make statistical projections on the basis of such limited studies. Since homeopathy considers the patient as a whole and includes number of variables in assessing the status of health and sickness, I argue that in future, if sufficient data is obtained about the efficacy of homeopathic treatment in various disease conditions, and the data is then coupled with the individualized factors of a case, homeopaths may be able to provide more accurate prognosis for individual patients. - - - - - - - - ###- - - - - - - - Reference List Adler
et al. (2006) The Harmful cure observed by Hering and Kent in contrast
to Hahnemann’s concept of gentle restoration of health. Homeopathic
Links Vol.19 No.3 pp.121-127.
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