Perceiving the uncooperative patient in homoeopathic clinical practice: A case series
How to cite this article: Patil MK. Perceiving the uncooperative patient in homoeopathic clinical practice: A case series. J Intgr Stand Homoeopathy 2022;5:48-54.
Understanding a patient is one of the most difficult tasks a homoeopathic physician faces; every new patient presents a new challenge. Building a rapport with every patient is not only a crucial task for the homoeopath, not all patients cooperate with the process, which in itself could be an individualistic feature. To perceive a man in disease, the homoeopath must be a master of interview techniques to create a Hahnemannian integrated totality, which is a challenging task. This paper demonstrated the role of the interview technique in perceiving the uncooperative patient to define therapeutic problem definition and resolution in homoeopathic clinical practice. Listening, observing, questioning, interpreting confronting and empathising were effective interview techniques to successfully create a Hahnemannian integrated totality to understand the man behind the sickness in uncooperative patients. This study demonstrated the successful application of interview techniques that enable a homoeopath to understand a patient as a person through the complaints in terms of integrated Hahnemannian totality to construct a therapeutic problem resolution.
Therapeutic Problem definition and Resolution
A case well taken is half cured. 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. 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. 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. Nearly one of six outpatients is difficult in clinical practice; these patients evoke negative emotions such as anger, guilt and hatred in physicians. The appropriate use of communication may improve the physician-patient relationship.
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. 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.
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
Source of data: Patients reporting to the outpatient department of a private urban clinic
Study design: Observational case series study
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
Patient consent not required as identity is not compromised.
The following criteria were included in the study:
Adults and elderly people (Age group 18 years- 85 years).
The following criteria were excluded from the study:
Children (Below 18 years of age).
The patient was a 35-year-old man working in a multinational company as a software engineer. The patient was bald with an average build.
Patient-physician interaction is shared below.
Physician: How can I help you?
Patient: My knee is paining for 1 year. Do you have any solution for it?
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.
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
Problem definition: Arrogance and scepticism.
Dictatorial – talking with air of command ++.
Mocking – sarcasm +++.
Contradiction – disposition to contradict ++.
Food and drinks – warm food – desire +++.
Senility – premature ++.
Extremities – pain – knees – right ++.
Repertorisation: [Figure 1].
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.
Final selection: Lycopodium.
Corresponds Mind 3+Body 2
Potency and repetition: 200C potency and single dose after 15 days.
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.
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.
Thermal: Cannot tolerate winter. Chilly ++.
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:
Problem definition: Timidity and benign tumour of the salivary gland.
Fear of pins, pointed and sharp things +++.
Thermal chilly ++.
Perspiration – foot – sole ++.
Perspiration – hand – palm ++.
Mouth – tumours – general ++.
Repertorisation: [Figure 3]
From the above repertorisation sheet [Figure 3], Silicea corresponds the most with all characteristic mental state and disposition.
Final Selection: Silicea
Tissue level susceptibility low
Corresponds mind ++ body ++
Potency and Repetition: 30C daily at night for 15 days.
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:
Problem definition: 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.
Final selection: Ambra grisea
Posology: Sensitivity high. Corresponds at mind +++
Potency and repetition: 1M potency and single dose.
The itching was 80% better in the 1st week; she could report within visiting hours. After a 2nd dose of Ambra grisea 1M in the 3rd week, the itching was 90% better. The patient visited after 3 months and reported no episodes of itching in the past 3 months.
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
Problem definition: Attachment.
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.
Final Selection: Kali carb
Posology: Sensitivity moderate to high
Potency and Repetition: 200C potency and single dose.
The patient reported after 2 months with no disturbance of sleep and quality of sleep improved.
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.
|S. No.||Type of difficult patient||Interview technique||Observations||Therapeutic problem definition||Therapeutic problem resolution|
|Case 1||Highly educated||Listening Observing Questioning Interpreting
|Loud tone of Speech. Sarcastic facial expressions||Premature senility||Lycopodium200C|
|Case 2||Poor self-awareness||Listening Observing Interpreting||Nervous expression on face. Talking hesitant.||Cowardly||Silicea 30C|
|Case 3||Modesty||Empathising Listening Observing Interpreting||Awkwardness. Nervous expression on face||Embarrassment||Ambra grisea 1M|
|Case 4||Uneducated||Listening Observing Interpreting||Unable to comprehend the importance of history.
|Attachment||Kali carb 200C|
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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