Significance of repertory in homoeopathic curriculum

Repertory has central significance for ensuring that homoeopathic practice is transparent and explicit but has a rather marginal significance in the curriculum weightage. In fact, the curriculum for repertory in both undergraduate and postgraduate courses is epistemologically lean and rather loaded with repertory books that are seemingly not frequently referenced in the homoeopathic clinical practice, especially so in the postgraduate course. This is not to denigrate the utility and importance of any repertory but only to underscore the priorities that seem to be not focused on developing professional clinical competence.

The need, therefore, is to take a dispassionate view of the significance of repertory in homoeopathic curriculum and think of some out-of-the-box options that can drive homoeopathic practice into the mainstream of clinical decision enlightenment that seems to be percolating into the healthcare domain. The challenge in this exercise is to introspect on the significance of repertory as a subject in the homoeopathic courses and seek a transformative resurrection of repertory as a meaningful dimension of practical homoeopathy.

Pierre Schmidt, a towering figure in the homoeopathic pantheon, remarked with gravitas on the role of repertory that ‘no one can know everything; and that is why in all honesty one must admit that no conscientious homoeopathic doctor can practice homeopathy in a serious and scientific way without a repertory’.^[1] This sentiment underscores the influence that repertory has on making homoeopathic practice logical and intelligible.

Before we jump into the discussion on the significance of repertory in curriculum, let us differentiate the terms ‘curriculum’ and ‘syllabus’; these are generally misunderstood as being synonyms and, more often than not, used in a context that does not convey the actual meaning. Curriculum, as derived from a word that means track’, gives direction and guardrails to a course and is, therefore, an overarching document that includes the regulatory, administrative, strategic, and academic dimensions, among others. Syllabus, on the other hand, has the academic dimension alone and provides the depth and heft for the contents of learning.

In the development of curriculum, the three major sources^[2] are (a) society for its requirements from the profession, (b) the subject and its relevance for the societal needs, and (c) the learners for the professional competence that they are expected to develop. The ambient scope of the curriculum is to bring about desirable changes in the learners’ behaviour, which can be measured for knowledge, skills, and values/communication. ‘Desirability’ is based on what are the strengths of repertory and how it relates to addressing society’s healthcare requirements.

The proof of the repertory’s success in the homoeopathy curriculum can be audited on how its strengths and challenges in providing a reasoning base for homoeopathic methodological decisions. There is also a need to define specific tasks that are incumbent on a homoeopathic professional and which attribute their source to the repertory. Based on these inputs, the content and duration of learning can be described. This is the canvas on which we need to illustrate the relevance of repertory in the homoeopathic curriculum.

Looking at the curriculum development process from the perspective of repertory as a subject in the homoeopathic courses, we can reflect on the current state and project for the future as a transformative option.

Designing a curriculum does not necessarily ensure that it will be a smooth ride all the way; there will be many obstacles and challenges that test the resolve and commitment of both learners and mentors. The leaders of the profession must foresee such downturns and energise the system to succeed.

By the end of this presentation, I would like you to –

• Discuss the importance of evidence-supported decisions in clinical practice,

• Relate repertory as a decision-making tool,

• Scrutinise the available data to complete a coherent cluster of information to base the clinical decision,

• Expound the concernment of repertory for the transformation of homoeopathic methodology, and

• Demonstrate metacognitive awareness of self, context, and resources in homoeopathic methodology.

The evidence-based approach to decision-making is characterised by the application of critical thinking and the use of the best available evidence.^[3] Defined by Dewey^[4] as ‘active, persistent, careful consideration of a belief or supposed form of knowledge in light of the grounds that support it and the further conclusions to which it tends’. Critical thinking is a skill crucial to evidence-based practice in healthcare and education^[5] and is being accepted increasingly as integral to the medical curriculum,^[6] which is vindicated by studies which show that improving evidence-based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment.^[7]

Barends^[8] described the evidence-based decision as being based on information, facts, or data supporting or contradicting a claim, hypothesis, or assumption. Applying this to the domain of healthcare, Sackett et al.^[9] described evidence-based medicine (EBM) as the integration of best research evidence, clinical expertise, and patient values. Incan is seen that the spirit of homoeopathic principles is closely aligned with the principles of EBM; if only the practice also resonates with it!

Clinical practices in the mainstream healthcare domain have adapted the emerging and future technologies, and this includes tuning in with the comforts of digital blessings. This has led to the integration of various aspects of patient care into a confluence of activities that are collectively recognised as a ‘Clinical Decision Support System’ (CDSS). This endeavours to improve healthcare services by enhancing medical decisions integrated with clinical knowledge, patient information, and other health information.^[10]

If we overlay the essence of CDSS onto homoeopathic methodology, the collection of data, its analysis, and interpretation that are precursors to repertorisation, we can see a striking resemblance between the two. What emerges from these exercises is the spectrum of clinical decisions that include diagnosis, prognosis, potency selection, prescription, follow-up, and prevention, among many others.

Looking closely at the structure of the CDSS software as described by Sim et al.,^[11] it is designed to aid clinical decision-making in which the characteristics of the individual patient are matched to a computerised clinical knowledge base, and patient-specific assessments or recommendations are then presented to a clinician for a decision. This looks utterly like the role that repertory software plays in homoeopathy.

If we further explore the DECIDE model of decision-making,^[12] the first three components are the mirror image of the repertorisation process, while the 4^th component relates to referencing Materia Medica to identify the best alternative. The 5^th and 6^th relate to patient management as a whole and clinical audit for feedback to learning.

At this stage, let us pause and reflect on the current state of repertory as a subject in homoeopathy courses.

The undergraduate course has two components – case taking and repertorisation, with the study of four commonly used repertories.^[13] This looks fairly sufficient to provide a cognitive base for the understanding of repertory as a medium for prescription. This is bolstered by the learning of case taking and case analysis that are built-in as the preparatory requirements for repertorisation. The focus is on understanding repertory as an adjuvant tool that displays a pattern of symptom-medicine order that either shortlists the medicines for prescription, or reveals some obscure medicine as a probability. The entire exercise of using a repertory is akin to a database to process the symptoms.

The postgraduate curriculum^[14] extends from the platform of undergraduate competencies and makes an expansive volume of ‘who’s who’ of repertory books. The sad part of such a generous dose of books is that the quintessence of repertory as an influencer for prescription-related decisions gets diluted, and its sublime scope as a terministic screen that simplifies the maze of symptom-data gets trivialised with many competing repertory books jostling for the same attention.

The absurdity slips condescendingly for idealising the ‘rubrics’ in some nondescript repertory, even though similar information would be available with far more completeness in the general repertories. What is glossed over in the effort to pack repertories in the postgraduate curriculum is that possibly some of the authors drew the information from the same general repertories and customised it for their personal requirements. The requirements do change from person to person and context to context unless these are codified under a policy that is consistent for all time. The horrors of such adventure are grossly evident in the university examinations where the students are compelled to make a paean of praise for the repertory that they might have hardly used, and the examiners often mark such answers with little evidence of the same.

Against this backdrop, there is a need to make a courageous admission of the reality and explore the sandbox for Promethean options. The suggested shift is to redefine and design the study of repertory as a decision-making resource rather than as a volume of symptom database spread over a multitude of repertory books or conflated into software without being mindful of the distinctness of the principles and architecture of the different repertories.

The submission is to consider repertory as an underlying anchor that organically unites all the elements of the homoeopathic methodology. The study of repertory can morph for the development of algorithmic flow to analyse and interpret the patient data and match the synthesis of patient information with the predetermined symptom base that is sifted from various repertories with due validation and vetting of symptoms. Such a symptom base shall conform to a unified homoeopathic philosophy of case and symptom analysis so as to create a platform agnosticism of homoeopathic methodological discourse.

As van Baalen and Boon^[15] assert, the alternative epistemology for clinical decision discourse, in their view, holds doctors accountable for epistemic considerations in clinical decision-making toward the diagnosis and treatment plan of individual patients. For customising the clinical decisions that are specific and singular to individual patients, the key intellectual challenge for doctors is their ability to bring together heterogeneous pieces of information to construct a coherent ‘picture’ of a specific patient. They consider such a ‘picture’ as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient. Similar efforts are made to develop personalised medicine as an expert guidance mechanism to improve patient outcomes, reduce financial burden, and avoid unwarranted practice deviations.^[16]

This is precisely the role that is envisaged for repertory in the homoeopathic methodological context: to develop processes and mechanisms of personalised medicine based on the algorithmic technique and reinforcing this system as health informatics, which uses information technology to organise and analyse health records to improve healthcare outcomes.

The process of evangelising repertory as the core of the information processing of patient data and symptom matrix includes the mechanism of ‘case analysis’ and ‘symptom analysis.’ There is some degree of confounding about these two phrases or functions among a majority of the students that I have come across. The simple differentiation is that case analysis is the dissection of the entire case to understand its various dimensions, whereas symptom analysis is to distinguish the uncommon or remarkable symptoms from the maze of common symptoms in the case. Thus, case analysis is overarching and includes symptom analysis as well.

Case analysis has four dimensions – (i) to establish the case in Hahnemann’s Classification of Diseases, (ii) to prognosticate on the basis of Dake’s Hypothesis, (iii) to track the disease progress as per Eizayaga’s trajectory, and (iv) to determine the operating ‘school of philosophy’ in the case.

Hahnemann has broadly classified diseases as dynamic and surgical^[17] and clarified the nature of each of the categories. The case shall be initially situated in the slot as per Hahnemann’s nosological taxonomy. The next step would be to predict the probability of a ‘cure’ in the homoeopathic context, which can be illuminated by the five postulates that close has modified from Dake’s hypothesis.^[18] The more significant operational dimension for case management is to identify the specific position that the disease state is in at any given time and how it is evolving so as to make germane clinical decisions. Eizayaga^[19] has advanced a model where the disease state can be mapped as it traverses a trajectory from birth till the end of life, signifying expressions as they evolve for each point in the arc of its progress.

Symptoms are analysed to sift the uncommon and remarkable from those that are common and generic to the disease state, which Boericke^[20] illuminates as basic and determinative symptoms, respectively. The operating philosophy of the case can be principally sorted as Boenninghausen-inspired, Kent-inspired, Boger-inspired, or Boericke-inspired.^[21] Each of these inspirations determines the policy for evaluating the symptoms. While on this topic, it would be informative to realise that the Boenninghausen philosophy has much in common with the Gestalt School of Psychology for the Doctrine of Analogy as it advocates to confluence symptoms for generalisation. Kent, on the other hand, drew inspiration from Swedenborg and Scudder for infusing a devotional dimension. Boger, though influenced by Boenninghausen, had a more pragmatic approach much like the importance that Boericke also vests for the clinical and pathology-based expressions in disease.

The concernment of repertory for narrowing the scope of prescription options is underscored by the interface of a multitude of factors and processes. These factors include the patient-doctor interactions and their outcomes, the process of harmonising the essence of homoeopathic philosophy and medicine information with the drug-disease symptom matrix, which is visible as a repertory. All these persuade us to reinvent repertory as a decision-enabling medium.

In the realm of healthcare education, the compelling determinant for internalising deep learning is ‘Self-Regulated Learning’.^[22] In this strategy, learning is metacognitively guided, intrinsically motivated, and strategically practiced. In fact, metacognition itself is recognised as one of the two most influential factors that moderate learning, the other factor being learner motivation. Being metacognitively conscious means that the learner is aware of their way of learning and that they know and understand the strengths and limitations of their learning aspirations, capacities, and confidence.^[23]

Metacognition can be defined as ‘knowing about knowing.’ There are generally two components of metacognition: knowledge about ‘knowledge’ and regulation of ‘knowledge.’ Flavell,^[24] who first used the word ‘metacognition,’ describes it as: ‘Metacognition refers to one’s knowledge concerning one’s cognitive processes and products or anything related to them, e.g., the learning-relevant properties of information or data.’

The more you are aware of your thinking processes as you learn, the more you can control such matters as goals, dispositions and attention. Self-awareness promotes self-regulation. If you are aware of how committed you are to reaching goals, of how strong your disposition to persist, and of how focused your attention is on a thinking or writing task, you can regulate your commitment, disposition, and attention.

To increase your metacognitive abilities, you need to possess and be aware of three kinds of content knowledge: declarative, procedural, and conditional. Declarative knowledge is the factual information that one knows; it can be declared – spoken or written. Procedural knowledge is knowledge of how to do something, of how to perform the steps in a process. Conditional knowledge is knowledge about when to use a procedure, skill, or strategy and when not to use it, why a procedure works and under what conditions, and why one procedure is better than another. It is the ‘when’ or ‘why’ of learning. Metacognition is regulated by three processes: planning, monitoring, and evaluation. Further, maintaining motivation to see a task to completion is also a metacognitive skill.

In this concept paper, I further advocate for reinventing repertory as a strategy to create filters for evidence-based clinical decisions in the domain of homoeopathic practice. Such an approach can add a dimension of transparency and tenable functionality to homoeopathic methodology. To achieve this goal, there is also a need to embrace the principles of educational methodology and the spirit of self-regulated learning.