Oxford Handbook of Clinical Medicine, 9th edition

Oxford Handbook of Clinical Medicine, 9th edition

Title: Oxford Handbook of Clinical Medicine, 9th edition (March 9, 2014)

Reviewed by: Ashok RajGuru

Authors: Murray Longmore, Ian B Wilkinson, and others

Publisher:  Oxford University Press

Type: Flexibound, 920 pages

ISBN-10: 0199609624

ISBN-13: 978-0199609628

Price: USD 46.69, (INR 525 on amazon.in, Kindle edition INR 498.75)

It is quite unusual to review a book dealing with allopathic medical practice in a journal devoted to Homeopathy. But the reviewer would like to plead that for a true healer, there is only one Art of Healing. As an ancient text says, “Truth is One, the Wise call it by various names” [1]. The book under review is the Oxford Handbook of Clinical Medicine (OHCM), and over the past 25 years it has been considered a guiding star by practitioner and student alike. The book is now in its 9^th edition. It has often been described as a cheat-book that doctors can use in wards. Interestingly, OHCM was banned from various UK medical schools for making medicine “too easy” [2]! It has had rave reviews on various forums, so this review shall skip those details here, and will focus on what is relevant to the homeopathic practitioner, teacher, and student.

About medical practice

OHCM is not just a compendium of medical data – it is full of practical advice, and is interspersed with interesting anecdotes and plenty of wit, humor and wisdom. The handbook acknowledges that although the readers would have studied anatomy, physiology, pathology and other medical subjects, they remember little, principally due to the sheer volume of data. As Somerset Maugham (who abandoned his medical career to become a novelist) had famously said, it was better to have learned and lost this information than to have never learned it at all! That is where this book proves useful. The authors’ stated objective is to “move a cumulative memory burden from the mind into the pocket”. Thus, it has over 900 pages, but thanks to the superior paper, flexible binding and clear print quality, it sits comfortably in a coat pocket. It has 20 chapters that cover every specialty.

The authors have unwittingly enunciated every principle of medical practice exhorted by Hahnemann in the Organon over 250 years ago – only by restating it in an elegant and poetic contemporary language (sadly without acknowledging Homeopathy or Hahnemann even once!). The reviewer feels that the first two sections of OHCM are a must-read for every healthcare professional. The first covers topics often ignored in practice, namely, professional ideals, ethics, bedside-manner, case-taking, medical statistics, attending to death and above all, patient care. The second is about history and examination. It covers symptoms and signs that one is likely to miss or see in the first encounter.

Do no harm

The Golden Rule of practice, “First do no harm” – is an edict that is constantly emphasized over and over again, with illustrative examples in virtually every chapter. This is especially important because, as the authors mention, it is difficult at the outset to determine the seriousness of each symptom. A pain in the toe may be just an injury overlooked by the patient or it may be caused by an embolus which may prove to be critical. Hence the authors make the audacious statement that “medicine is for gamblers – gamblers who are happy to use subtle clues to change their outlook from pessimism to optimism and vice versa”. (Emphasis appears in the original text). And further, “Gambling is your job. We would all rather have a lucky doctor than a wise one.”

On ideals

The authors admit that ideals are like stars – they’re hard to reach but helpful for finding your way in the dark. They also remind us that our patients are people, and one must be careful not to refer to them as Miss Sepia or Mr. Nux Vomica. Such sanitized, dehumanized descriptions only distance us from our patients. We must infuse optimism, as optimistic patients feel in charge and live longer and happier.

The OHCM is replete with stories and anecdotes that convey the importance of compassion in the healing journey. In the opinion of the reviewer, there is a deficit of homeopathic literature in this area. Of late we have become too obsessed with “cases”, with remedies, kingdoms and results. Today our journals and books rarely have any “healing story” where our remedies have touched the lives of people. But this was not always the case. Dorothy Shepherd always weaved such stories in her narrative description of remedies. Perhaps educational curriculum in Homeopathy needs to introduce courses in literature as American allopathic medical schools have done since the mid-1970s. This will help us homeopaths to develop skills in the human dimensions of medical practice. It will help us to develop empathy, and deepen our capacities for reflection and self-knowledge. Besides it will help the cause of Homeopathy in the West where attacks and ridicule by skeptics are on the rise. Deepak Chopra, Bernie Siegel, Christiane Northrup, Larry Dossey, Lisa Rankin, Joan Borysenko, Herbert Benson and scores of other mainstream allopathic MDs have influenced attitudes in the field of medicine to make Yoga, Meditation, TCM, Ayurveda and other systems of healing more acceptable. The reviewer hopes that one day brothers and sisters from our homeopathic community will join the ranks of the writers mentioned.

The golden ray of hope is that the publishers and editor of this journal have initiated a fiction and short story competition from homeopaths.

As practitioners of the Healing Arts, we are reminded that healing encompasses health, wholeness and happiness. The magic of the minimum dose may at times fail to shrink a tumor, but if the person “takes his cancer for a walk like an unruly pet,” can we not say the remedy has worked? We need more stories in homeopathic therapeutic literature where disease has been trumped by a person and used, say, as a vehicle to crusade for the promotion health, and thereby attain that higher purpose of our existence Hahnemann talked about [3]. After all, our remedies work on the totality of the person, not just on objectifiable laboratory findings.

On symptoms

The authors of the book have succinctly summarized the importance of symptoms with a compassionate lament – “If only we could live long enough to suffer from every disease, then we could be of real service to our patients. …we would understand angina from the inside, and the fire of zoster’s pain would no longer mystify us.” But we, from the Homeopathic School of thought, are blessed that our remedies enter the Materia Medica after substances (or imponderabilia) have passed the metaphorical trial-by-fire of provings on healthy individuals (now appropriately called homeopathic pathogenetic trials), and not by trial and error on the sick and infirm. Since Homeopathy lays such great importance to symptoms, the OHCM provides a fresh perspective on why we should refer to source books of provings, and not just the repertory or even materia medica.

In an earlier edition (8^th), the authors compared symptoms presented by the patient to “kites and spinnakers flying in the slipstream of the practitioners wavering attention”- often to be ignored or obsessed about. These symptoms are routinely analyzed and ripped apart for diagnosis and for scientific explanation of disease; but what is sadly overlooked “are the strings which attach these volatile symptoms to the person”. Isn’t it a beautiful way of expressing the necessity of individualizing each case? The question we must ask ourselves, as practitioners of the Medical Arts is, “What must this person be feeling to have come up with this description of their condition”? There is angst in the hearts of the authors as they exhort the readers to ensure that they are not “severing the kite from the earthly lives of our patients”. In our search for a remedy, we must not lose our compassion for the suffering borne by our patient.

The book can prove very useful to a homeopath in descriptions of certain symptoms not commonly seen by them. For example, it is well known that patients suffering from a heart attack do not usually consult a homeopathic physician. They go to a cardiologist, and the homeopath is called in only when there are complications that do not respond to modern medicine. Thus, very often homeopaths do not get the opportunity to observe the symptoms firsthand at the onset of a heart attack. We have a very rich Materia Medica to describe symptoms, but a practitioner may be lacking in experience. For example, OHCM comes in handy to explain, surprisingly, that patients mostly avoid using the word “pain” to describe ischemia. The language of the patient is usually, “wind”, “tightening”, “pressure”, “burning”, or a “lump in the throat”. There can also be non-verbal clues, like a clenched fist placed over the sternum. Such descriptions can so readily help us to find a remedy. It is also pointed out that when the patient describes a pain as “sharp”, it describes severity of the pain, not its character. This can be a great help in choosing appropriate rubrics.

Epidemiology

This section is a very good briefing on Evidence Based Medicine; medical statistics and what they mean with regard to investigations; and Randomized Controlled Trials, their limitations and pitfalls. There are plenty of gems in this section.

One statement, based on statistical data, is quite instructive insofar as strange or rare symptoms are concerned. If a new symptom, s, rarely seen in an existing rare disease, D, but commonly found in another commoner disease, X, is found to appear in a patient already suffering from the rare disease D; then it does not mean that the patient is now afflicted with disease X. Doesn’t this round about statement, based on contemporary research and statistical laws echo Hahnemann’s thoughts relating to the action of a dissimilar stronger and older disease on a new, weaker disease?

All this is important to the homeopath, who must remember, that before treating symptoms one must understand underlying pathologies. And importantly, all laws have exceptions – if the patient is doing well on the “wrong” remedy, it is the right one!

Symptoms as side-effects of allopathic drugs

Many patients that come to homeopaths are taking allopathic treatment and are under a poly-pharmacy regimen. For example, a person may be taking a combination of one or more of these: diuretics, thyroxin (hypothyroidism), ACE inhibitors or ACE receptor inhibitors (hypertension), salbutamol (asthma) or ergot alkaloids (migraine). All these could have as side-effect muscle cramps in the legs or a writer’s cramp. This information can help to keep these symptoms low in our priority for repertorization as they are drug induced symptoms and are not characteristic of the patient or the disease.

To quote another example, a person without any clinical evidence of heart disease may present with an acute cardiac rhythm following a weekend of binge drinking or use of marijuana. This is called the holiday heart syndrome and should be handled by advice to the patient to abstain from excessive use of alcohol. Also, cardiac pain is unlikely when it is stabbing/ shooting; lasts less than 30 seconds, however intense; is well localized, left sub-mammary pain. The OHCM is a goldmine of such information.

The authors discourage dependency on medicines and advise practitioners to start with simple modalities first and go for complicated treatments last. This is summed up in a rather queer mnemonic which should guide the physician: B-A-S-T-A-R-D. It stands for Buy over-the-counter-stuff; take Advice from the grandma; use Self-made remedies such as lemon-and-honey, (or sensible alternative therapies); Team up with people with the same condition; Augment your own mental health and resilience so that symptoms are less intrusive; Rest (or exercise); and eat a sensible Diet. Drug intervention should begin only if all these fail!

On case-taking skills

Case-taking lies at the heart of the Homeopathic Art. The authors seem to be echoing the Organon when they caution the practitioner to listen to their patients with “as rapt attention as they would while reading a good book”. We must not allow our analyzing, logical, scientific, explaining self to take over and get involved in explaining our patient’s narrative. The human mind is conditioned to see everything through something – we are always looking at an image refracted by the lens of our experience, or our biases, or something else. Are we trying to work out a case by refracting through the lens of a Periodic Table or a Family? Or are we trying to fit in a Miasm or a Kingdom while the story is being narrated? Such digressions and distractions during the process of case taking can only lead us astray from the patient’s concern and take us into our own cocoon of constructs and theories, so vehemently opposed by Hahnemann [4].

Asking questions is an art. The advice is, ask open ended questions, ask fewer leading questions and respond to patient’s cues. One way is to try and repeat and reflect the last words said – it could open a new route to new “intimacies”. The authors also ask us to leave space to allow people to talk, because, “Questions can only get you answers. If you interrogate a robin, he will fly away: but treelike silence may bring him to your hand”. While history-taking may appear deceptively simple, the authors caution that it requires alertness and tact to extract the correct information from what the patient is saying. For example the patient’s story may be a mix of hearsay (“She said I looked pale”), innuendo (“You know, it’s there, down below”), legend (“I suppose I bit my tongue, you know?”) to exaggeration (“I didn’t sleep a wink last night”). The skill lies in making sense of these statements, not ignoring them. A lot of information can be gathered without any verbal inputs, for example, foul odor from halitosis, the stench of cigarettes or alcohol can tell a lot. Another helpful tip is that it helps to periodically review or re-take a case in chronic cases as recollections change.

The book provides another easy mnemonic to ensure the chief complaint is thoroughly covered (as taught by Boenninghausen) – namely, S-O-C-R-A-T-E-S: Site (location/region); Onset (gradual, sudden); Character; Radiation (of pain); Associations (concomitants like sweating, nausea etc.); Timing (of pain, duration); Exacerbation and alleviating factors; and Severity (on a scale of 1-10).

Constructing narratives

Hahnemann states that the physician is a sustainer of health if he knows things that disturb health, and engender/ maintain disease and is aware how to remove them from healthy people [5]. The authors present an example of a person with a heart failure. One must try to answer the question “Why did it occur”? Let us look for associations – say the patient also has a concomitant anemia. Why is he anemic? It may be due to a poor diet. Is the poor diet an outcome of poverty? Is there some other reason? It could well be apathy to diet due to depression. Why is he depressed? It may turn out that he finds no meaning to life after his wife died last year – ending a happy fifty year old marriage. So it doesn’t matter to him whether he dies tomorrow. Then why has he come to me? You learn that he came in to please his daughter who looks after him. Aha, so there we are! His daughter is what matters to him, so if we wish to see him get better, we must include his daughter in all our efforts. Talking to her, involving her in his diet and exercise, and it will eventually enrich the patient’s life forever.

Another way is to construct an imaginative narrative to yield new meanings to the symptoms. To a patient, what does his limp mean? Is it just neuropathy or is it associated with falling behind in a mortgage payment – a sort of a financial limping situation? How will this help? One must realize that while science is about clarity and objectivity, the world is also about subjectivity and emotion. As any scientist dealing with complexity and chaos would tell us, there are always relationships between apparently unrelated phenomena. David Bohm had called all material manifestations as explicate expressions of a non-visible implicate order [6]. It is the Healer’s duty to discover that hidden, deeper dimension underling the presenting reality.

Is this book value for money?

In order to assess value for money, one must include the cost in terms of money, time and effort invested, and take into account the quality of the resource, fitness for purpose, and convenience to use. As mentioned above, this 920 page tome costs just a little over Rs. 500 (UK price GBP 25.75) – it’s the price of cinema tickets for two and a bag of popcorn. The size is indisputably handy. It is an excellent reference for almost any clinical condition, includes symptomatology, anatomical and physiological explanations along with related pathologies. And most of all, it is extremely readable. If the reviewer had to point out any shortcoming, it would be that some readers may find the type font very small. Also, the Epidemiology section should have been placed before the specialty sections, as was the practice in older editions.

References:

[1] Rig Veda: 1.164.46 (एकं सद्विप्रा बहुधा वदन्ति ekaṁ sadviprā bahudhā vadanti)

[2] Kelly Hewinson: Nine facts you may not know about the Oxford Handbook of Clinical Medicine (http://blog.oup.com/2014/01/nine-facts-oxford-handbook-clinical-medicine-ohcm/)

[3] Hahnemann S: Aphorism 9, The Organon of the Medical Art, 6e.

[4] Hahnemann S: Footnote to Aphorism 1, The Organon of the Medical Art, 6e

[5] Hahnemann S: Aphorism 4, The Organon of the Medical Art, 6e.

[6] Bohm D: Wholeness and the Implicate Order, Routledge, London, 1980, accessed from http://www.gci.org.uk/Documents/DavidBohm-WholenessAndTheImplicateOrder.pdf