The case of the biased patient by Keith Souter
I have chosen this rather tantalising title, which may seem suggestive of a Sherlock Holmes story, for a definite purpose. It is not meant to be perjorative towards the subject of the tale, as indeed it is presented with his approval. Rather it is illustrative of some of the difficulties that we face in homeopathic medicine, both as patients and as practitioners, and for that reason I suppose it would be more accurate to describe it as “The case of the biased patient and his biased practitioner”. In the hope that I have whetted your appetite and your curiosity, let us see how it all unfolds.
A challenging case
Many patients come to homeopathy almost as a last resort, having tried various therapies, including orthodox medicine, but without benefit. This was not the case with Gregory. Indeed, he had used homeopathy quite extensively over the years and was, like many homeopathic self-users, extremely well-versed in many of the remedies of the materia medica. “I think you will find me a challenge,” he said. “I have used homeopathy all my life and I am a strong reactor. I just need an outside help sometimes. You might spot something I have missed.”
Gregory was 43 when I first met him. He was the head of a department at a high school. He was in a second marriage and he had access to his two children from the first marriage every other weekend. He seemed to be on a myriad of committees, both connected with school and his various outside interests. He was neat, organised and always on the go.
“Arsenicum works for me a lot of the time,” he prompted. “You’ll realise that of course.” And pointing to the organised chaos of my desk and bookshelves he added: “I couldn’t work with that clutter. But obviously you can.”
His problem, as he saw it, was a difficulty with a persistently discharging ear. “I have tried all sorts. My GP took a swab – he wasn’t going to until I suggested it – and that was negative. I had umpteen different ear drops, but they were no use. An ENT surgeon couldn’t help. Not that I expected him to. And I tried treating it myself with Mercurius, then Hepar sulph and Graphites. No use.”
He was also tired a lot of the time. “But I am a teacher and the head of the department. That is no wonder. Oh yes, I am really chilly, that must tell you something.”
And so it went on as I took the history, with Gregory peppering it with little asides and suggested remedies. His ear canal did indeed seem raw and the skin looked excoriated.
So we agreed at last on a remedy and I prescribed Arsenicum album LM1 to be taken regularly. The LM potency scale is very gentle, as Gregory knew well.
Between the initial consultation and the next one I must have talked on the telephone several times to Gregory. Each time he gave me an update on his ear, and on how he was feeling generally. He queried the remedy, the potency and whether or not he should consider anti-doting the remedy.
At the follow-up consultation he came with a sheaf of notes of his symptoms, his response to medication and various questions that he wanted to ask about homeopathy. He was not in a good humour. There were problems between him and his ex-wife over certain financial matters. He was quite adamant that he was not going to give way, because: “It was all her fault in the first place.” In addition, he was cross with a colleague, whom he intended having words with over some professional matter.
Unfortunately, his ear discharge was no better. He gave a long-suffering sigh. “Have I got to put up with this forever?”
Then he told me about his excessive perspiration. “I sometimes take Calc carb. It works for me too. I think we are way off with the Arsenicum.’
And we agreed to try Calcarea carbonica, again in LM1 potency.
But not for long! Three days later Gregory phoned me up in quite an alarmed state and insisted on a further appointment. He had, it seemed, developed irritation with his haemorrhoids. He said that it was like sitting on a bunch of needles. And he was feeling dizzy.
“Can we try a different remedy?”
Reluctantly, I let myself be persuaded and prescribed Calc arsenicum 30c for three days. Gregory had features consistent with the remedy profile of both Calcarea and Arsenicum album, so it seemed reasonable.
Heuristics and bias
Frequently when you read the description of a case treated homeopathically it seems as if a few choice clues lead unerringly to the simillimum, the indicated remedy for the patient at that time. In practice, however, it may take several goes before the correct remedy is chosen. The thing is that homeopathy is an experiential therapy. By that I mean that the patient’s experience of their symptoms and the way in which they perceive those symptoms is highly relevant. It is not so much the fact that someone may have a discharging ear, but the way in which the ear discharges. Is it a clear discharge? A smelly discharge? A purulent discharge and so on. Is it painful, and if so, is it a burning pain, a stinging pain or an aching pain?
Judgement has to be made as to what we treat. Do we treat the local problem of the ear? Do we treat the anxiety surrounding the problem? Do we treat the so-called constitution? These are simple examples of the many questions that we have to answer in coming to a remedy suitable for the patient.
In homeopathic practice we have several tools that we can use. We have books called repertories and, increasingly common nowadays, computerised repertory systems. Effectively the practitioner elicits several significant symptoms and with a repertory or computer system cross references these with remedies that would be indicated for those symptoms. Thus a league table of indicated remedies comes up.
Yet judgement is never simple. Behavioural Decision research has indicated that when individuals are faced with a complex system and limited time to make a decision we use a number of unconscious simple rules of thumb or “heuristics”. Essentially, these are fairly successful and allow us to reach a quick answer. The problem is that the answer may well be biased.
Let me give you a couple of examples of heuristics. Firstly, “the recognition heuristic”. This is the “one good reason” rule of thumb. For example, you read an article in Health and Homeopathy about a remedy, Nux vomica, for example. The next day you will see several people who would benefit from it. The problem is that you will probably be right in several of the cases, but since heuristics have bias associated with them, you will tend to make some cases fit into your criteria. And of course the incorrect remedy will just not work.
My second example is “the affect heuristic”. This is a tendency to link emotions with thoughts. We unconsciously tag factors as being good or bad. Our subjective impressions about how we perceive people are also affected by this. In homeopathy we have a tendency to tag remedies as in Figure 1. This heuristic together with the recognition heuristic, commonly used by people with a good working knowledge of homeopathic remedies, is frequently used in selecting remedies for self-medication.
The remedy didn’t work!
Gregory returned and was not happy. He was losing faith in the process. So we sat down and candidly looked at a repertorisation of his case. The remedy Nitric acid showed up clearly.
“But that can’t be me, can it? Not Nitric acid!”
After some discussion, we tried it, and with a really excellent result. The discharge and the haemorrhoid discomfort both cleared up very quickly. But more significantly, it helped Gregory to relax. And this was something that he realised that he had never been able to do. And over the next few months, with judicious treatment, he seemed to mellow. He became less confrontational, less anxious and, dare I say it, less hypochondriacal. Later he was able to see and agree that he had a tendency to pester, to question, to hold grudges.
Keynote features of Nitric acid
Emotionally I would say that people needing Nitric acid tend to hold grudges, they may be irritable, pestering, negative, pessimistic and extremely anxious to the point of hypochondriasis. Physically, they are chilly and subject to warts, haemorrhoids, fissures, and suffer needle-like or splinter-like pains.
Biased patient – biased practitioner
Gregory was knowledgeable about homeopathy and had variable success with self-medication. But I suspect that he also knew that the individual’s experience of their symptoms is crucial. He was aware of what I have indicated in Figure 1 to be the “nasty” Nitric acid profile. It doesn’t mean that the individual is actually nasty in any way, but that we tend to tag it as such in the unconscious “affect heuristic”. Hence, Nitric acid never came into his reckoning, for he was biased against it. Therefore, the information that he presented to me drew me away from the indicated remedy. Yet I have to admit that I also was subject to the phenomenon of bias, which unconsciously veered me away from prescribing this highly valuable remedy for Gregory.
Keith Souter MB ChB FRCGP MFHom MIPsiMed DipMedAc is a part-time GP in Yorkshire. He also has a private holistic medicine practice and is a newspaper columnist as well as the author of Homeopathy for the Third Age and Homeopathy: Heart & Soul.