Perceiving the uncooperative patient in homoeopathic clinical practice: A case series

INTRODUCTION

A case well taken is half cured.^[1] The physician’s art of consultation provides the patient with the confidence to express their true form. The art of consultation demands consistent practice, especially in homoeopathy; it is a crucial task for every homoeopath to cultivate the skills of consultation for every individual case. Homoeopaths face difficulties in consultation due to the ignorance of patients who are not accustomed to providing a detailed narration of their complaints.^[2] The influence of modern medicine is evident in that people expect to follow the same procedure without providing many details and expect better results. Homoeopathic case-taking demands exploration of various life areas, which the patient may not like to disclose to the physician due to modesty, shame and insecurity. Patients may conceal the facts and provide inadequate information which makes the problem definition difficult. Not every patient is comfortable with a long duration of case taking, so a rapport cannot be established between the physician and patient in the first interaction. Establishing rapport enables the physician to understand the patient as a person.^[3] Rapport may not develop with patients who are poor in self-awareness, too highly educated or too poorly educated, traditionally prejudiced, violent, aggressive, verbally rude, manipulative, lying or demanding. The ‘difficult patient’ can be defined as one who impedes the clinician’s ability to establish a therapeutic relationship.^[4] Nearly one of six outpatients is difficult in clinical practice; these patients evoke negative emotions such as anger, guilt and hatred in physicians.^[5] The appropriate use of communication may improve the physician-patient relationship.^[6]

The most common and most effective means of establishing rapport is the use of empathy. The ability to be empathic towards a difficult patient makes the encounter much easier. Many physicians acknowledge that difficulty in being empathic may result from the physician’s personality, their work style, belief system, cultural gaps between physician and patient, the patient’s behaviour and external circumstances that affect the encounter.^[7,8]

The appropriate use of interview techniques is essential to deal with every individual case to perceive the therapeutic problem definition and resolution. Interviews should start with a personal introduction that establishes the purpose of the interview; this helps to build an alliance around the initial examination. The interviewer should make an effort to greet the person warmly and use words that show care, attention and concern. Computer use should be minimised; if used, should not interfere with continuous eye contact, especially when dealing with uncooperative patients. The secret to a successful interrogation is to always leave the patient free to establish a rapport with the physician. This allows the physician to understand the patient as a person; moreover, free communication affects a release of inner stress in the patient, which has considerable therapeutic value. Questions should be straightforward and precise. The physician should not make any inferences or suggestions regarding the response. The language chosen should be appropriate for the patient’s intelligence; great effort must be made to ensure that the words used to convey the intended message.^[9] To maintain a truly neutral attitude, the physician must always be vigilant. They should not participate actively in the patient’s problems or sit in judgment on them. The physician should be least concerned with right or wrong; they should be interested in understanding why and how the patient reacted in that particular manner. Successful interrogation demands appropriate use of interview techniques such as questioning, exploring, listing, observation, blocking, guiding, assurance, confrontation, counselling, silence, informing, interpreting, refusing, empathising, not accepting and role playing; the technique used may vary depending on the specific objectives defined for specific interactions. Questioning in a different context and with different wording is generally used to clarify certain points or to complete the fact and locate the problem through exploration. Listening and silence are essential techniques to encourage the patient to share the problem through verbal and non-verbal interactions; simultaneously observing gestures and expressions helps the physician derive a reasonable meaningful interpretation. This technique demands nothing but sound senses in a physician. Silence is especially useful when a physician expects the patient to cooperate along the lines indicated and the patient resists. During the interview, the patient may hesitate due to embarrassment or modesty. At that point, the patient needs to be reassured that they are accepted. This interview process is entirely dependent on the interviewer’s ability to obtain from the patient a highly distinctive conceptual image of the illness. The process is facilitated by early diagnosis and a correct appraisal of objective data of disease through sizing up by attending to personal details like the way the patient dresses, their posture, carriage and demeanour and mannerisms. The physician’s impressions about the patient commence right from the moment the patient enters the consulting room.^[10]

Therefore, four treated cases were selected to share the physician’s experience and thought process to perceive the therapeutic problem definition and resolution in uncooperative patients in homoeopathic clinical practice.

MATERIAL AND METHODS

1. Source of data: Patients reporting to the outpatient department of a private urban clinic

2. Study design: Observational case series study

3. Suitable interview technique used as per the ICR Operational Manual to perceive a man in disease in difficult or uncooperative patients to create a Hahnemann integrated totality

4. Patient consent not required as identity is not compromised.

CASE SERIES

Interview

Physician: How can I help you?

Patient: My knee is paining for 1 year. Do you have any solution for it?

Physician: Yes.

Patient: Are you sure homoeopathy can help me? (Loud speech with sarcastic expression).

Physician: Yes. Homoeopathy can help you.

Patient: How many years you have studied homoeopathy? I mean time duration of homoeopathy course as an academic (sarcastic expression).

Physician: Almost 9 years including postgraduation.

Patient: Oh!! Really! What you are saying? I cannot believe it. What is in that homoeopathy to spend 9 years to study as an academic course? Australia proved that homoeopathy is pseudoscience and banned it.

Physician: Hmm…. (Pause).

Patient: I have a doubt even homoeopathy works or not? Do you sure homoeopathy will help me? (In loud speech) How sugar pills can cure anything? (Sarcastic expression)

Physician: Then, why did you consult me?

Patient: I have been told by my dentist to consult you and I am sure sugar pills will not harm like a painkiller.

Physician: So what you have decided. Do you want to start homoeopathic treatment or not?

Patient: Yes. Why not! Let’s see whether it works or not? (Sarcastically)

Physician: We need all your details about your life history such as food cravings, aversion, heat or cold tolerance and your nature; the case needs almost 45 min for a better outcome of treatment.

Patient: I came for knee issue only.

Physician: Pause

Patient: I cannot tolerate heat and summer but I love hot food. Focus on my knee.

Physician: Let me examine your knee.

Patient: Ok. See this right knee is affected only.

The interview was concluded shortly after.

He had only right knee joint pain for 1 year with no specific modalities.

Right Knee O/E: Swelling ++ No Redness. Crepitation ++ ROM: Full.

Radiograph: Right knee osteoarthritic and degenerative changes.

Interview techniques used to deal with patient

1. Listening

2. Observing

3. Questioning

4. Interpreting

5. Confrontation.

Case analysis

Problem definition: Arrogance and scepticism.

Totality

Dictatorial – talking with air of command ++.

Mocking – sarcasm +++.

Intelligent ++.

Contradiction – disposition to contradict ++.

Contemptuous ++.

Food and drinks – warm food – desire +++.

Senility – premature ++.

Extremities – pain – knees – right ++.

Thermal: Hot.

Repertorisation: [Figure 1].

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Figure 1:

Repertorisation.

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Remedy differentiation

Lycopodium, Lachesis and sulphur came up for differentiation. Craving warm food and right-sided location are not covered by Lachesis, so it was ruled out. Sulphur and Lycopodium were very close [Figure 1]. However, the mocking and taunting behaviour is well marked in Lycopodium; therefore, it seemed to be the most suitable similimum.

Problem resolution

Final selection: Lycopodium.

Posology:

• Corresponds Mind 3+Body 2

• Pathology: Structural

• Vitality: Good

• Susceptibility: Moderate.

Potency and repetition: 200C potency and single dose after 15 days.

Follow-up

The knee pain was reduced by approximately 80% after one dose of Lycopodium 200C. The patient acknowledged homoeopathy as a valid system of medicine in the next follow-up and then brought his family for treatment. Over 6 months, the knee pain was significantly better.

Case 2

A 22-year-old man, an engineering student, reported a complaint of a soft solitary movable tumour below the tongue for 1 year [Figure 2]. There was no pain or other associated symptoms. The tumour was diagnosed as a benign tumour of the salivary gland by an ENT surgeon. The patient had been recommended surgery, but he refused as he was afraid of surgery.

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Figure 2:

Nodular swelling before treatment.

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Thermal: Cannot tolerate winter. Chilly ++.

Local examination

Soft solitary movable pea-sized tumour below the tongue.

No submandibular lymph node was palpable.

Observations: Lean, thin and fair complexion. He was nervous, shaky and hesitated while talking and most often he was just nodding his head as a reply to question. He was not ready to share anything about his life despite being oriented toward the importance of life history in homoeopathy. He was afraid of physicians, especially of injections and surgery.

On examination, the patient had perspiration on their palms and soles.

Interview techniques used to deal with the patient:

1. Listening

2. Observing

3. Interpreting

4. Questioning.

Case analysis

Problem definition: Timidity and benign tumour of the salivary gland.

Totality

Fear of pins, pointed and sharp things +++.

Reserved ++.

Cowardice ++.

Thermal chilly ++.

Perspiration – foot – sole ++.

Perspiration – hand – palm ++.

Mouth – tumours – general ++.

Repertorisation: [Figure 3]

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Figure 3:

Repertorisation.

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From the above repertorisation sheet [Figure 3], Silicea corresponds the most with all characteristic mental state and disposition.

Problem resolution

Final Selection: Silicea

Posology:

• Tissue level susceptibility low

• Corresponds mind ++ body ++

• Pathology: Structural.

Potency and Repetition: 30C daily at night for 15 days.

Follow-up

Within 15 days, the tumour disappeared completely [Figures 2 and 4].

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Figure 4:

After the treatment resolution.

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Case 3

A 47-year-old fair, thin and nervous woman arrived when the clinic was closing and no one was around. She felt awkward while talking and was not ready to visit during the visiting hours. She was narrating her complaints in a very low voice while standing. She reported on and off itching in the vagina for the past 4 years; antifungal medications provided no relief. Due to the itching, she avoids public places and functions out of awkwardness and is worried before going out. Even at home, she would go to the washroom to scratch the affected area so that no one would see her. She requested for medicine that would help her to sit in the clinic without itching at least during the consultation period.

Interview techniques used to deal with patient:

1. Empathising

2. Listening

3. Observing

4. Interpreting.

Problem definition: Embarrassment.

Totality

Embarrassment

Timidity – company, in Looked at; to be – cannot bear to be looked at Anxiety – company; when in Fear – observed; of her condition being.

Repertorisation: [Figure 5]

From the above repertorisation sheet [Figure 5], Ambra grisea corresponds with all the characteristics of the mental state.

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Figure 5:

Repertorisation.

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Problem resolution

• Final selection: Ambra grisea

• Posology: Sensitivity high. Corresponds at mind +++

• Potency and repetition: 1M potency and single dose.

Follow-up

The itching was 80% better in the 1^st week; she could report within visiting hours. After a 2^nd dose of Ambra grisea 1M in the 3^rd week, the itching was 90% better. The patient visited after 3 months and reported no episodes of itching in the past 3 months.

Case 4

A 56-year-old fair and stocky woman with swelling on her eyebrows consulted for sleep disturbance for 1 year. Her speech was quite hasty. She stated that she was absolutely healthy except her sleep disturbance; she would wake up at 3 am and would be unable to sleep again. She requested with folded hand to focus on her sleep only and resolve the issue, she was not responding freely to any other questions by the physician. She could not acknowledge the importance of history taking in homoeopathy. Her husband had been the secretary of their cooperative housing society for a year; some society members were quite rude to her husband, which caused anxiety.

There were no significant characteristic physical general available in the case except the thermal state which was towards chilly.

Interview techniques used to deal with patient

1. Listening

2. Observing

3. Interpreting

4. Questioning.

Problem definition: Attachment.

Totality

Mind – ailments from – anticipation

Mind – begging

Mind – shrieking – help; for

Generals – night – midnight – after – 3 h

Eye – swelling – eyebrows.

Repertorisation: [Figure 6]

From above repertorisation [Figure 6], Kali carb corresponds in terms of characteristic causative modality and time modality with swelling of the eyebrows.

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Figure 6:

Repertorisation.

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Problem resolution

• Final Selection: Kali carb

• Posology: Sensitivity moderate to high

• Susceptibility: Moderate.

Potency and Repetition: 200C potency and single dose.

Follow-up

The patient reported after 2 months with no disturbance of sleep and quality of sleep improved.

DISCUSSION

To accommodate the system of case receiving, physicians prefer patients who are trusting, cooperative and non-demanding. Physicians face difficulties during interviews when dealing with illiterate patients, traditionally prejudiced, poor in self-awareness, violent, aggressive, verbally rude, manipulative, lying or demanding. These patients generally do not follow the physician’s instructions, which impedes the clinician’s ability to establish a therapeutic relationship.

However, while dealing with such patients, the physician’s personality and disposition play an important role in the interview technique. In our cases, questioning, listening, observing, silence and interpreting techniques were used to deal with uncooperative patients. Confrontation and empathising were used in Cases 1 and 2, respectively. The questioning technique was frequently used to collect information. In this study, the listening and observing techniques were frequently used in all cases. Listening encouraged the patient to talk and share their problem, which, in turn, assisted in defining the problem. Observation is a continuous concurrent process used in interviews wherein the physician listens not only to what the patient says but also to how they say it. Listening, observing and confronting interview techniques aid in understanding aggressive, verbally rude, manipulative, lying and demanding patients. Silence is another effective technique that can be used whenever the physician feels resistance from the patients. The interpretation technique enables a physician to derive meaning from collected facts and observations that adequately explain the phenomena observed in the patient. In Cases 2 and 3, an empathetic attitude by the physician towards the patient’s suffering assisted in managing the patient’s modesty and anxiety.

Many interviews are not anticipated to go well and issues may occur based on the nature of the problem being addressed, the type of patient being interviewed and the type of physician conducting the interview. If physicians can accurately analyse the challenges, they will be in a better position to deal with them.

CONCLUSION

The appropriate application of suitable interview techniques enables homoeopaths to understand the person behind the sickness in terms of Hahnemannian integrated totality in uncooperative patients for therapeutic problem resolution.

However, this is a small sample case series and further studies with different study designs and larger sample sizes are required to further evolve the art and skill of interview techniques for use in uncooperative patients.