When does an Acute Clinic become Chronic
When I first started volunteering at a homeopathic drop-in clinic in the North East it was to amass RSHom hours for my clinical practice. However after a couple of week’s attendance I realised that I loved the fast pace and rewarding results that could be seen in patients week after week. Being an acute clinic advertised as dealing with first aid situations I expected wounds, colds, shock etc. however the longer I spent with the clinic the more I began to realise that the line between acute and chronic can become very flimsy.
The clinic is based in a women’s health building which promotes integrated holistic health. The range of worries and concerns for many of its patrons run deep and it is inevitable that many of the problems brought to clinic are an acute manifestation of a chronic underlying problem.
The clinic sees an average of 9 patients a week; some weeks there can be as few as 4 and some weeks 18 patients can be seen. Officially the clinic runs for two hours between 12.15 and 2.15pm; however more often than not this time can run over as the homeopaths ensure they see everyone that requires help. Each patient, based on an average of 9 per week, sees the homeopath for 13 minutes.
Having come fresh from college where the average initial consultation time was 1 ½ hours to take a full case history, I was amazed at the quick deduction methods of the homeopaths who made up their mind about remedies based on very few characteristic signs. My own experience of acute prescribing had been limited to family and friends at the time, and even that would take me longer than 15 minutes with my repertory and materia medica to clarify I’d got it right. I accepted of course that their experience (roughly 25 years between them) meant their judgements were based in rich knowledge however it still surprised me that this same method would be utilised for chronic prescribing also.
I found myself remembering a tutors words back at college when the class would ask for advice to give to a friend who had come for an acute problem. She would tell us to question if the problem was really an acute manifestation of a chronic issue and then laugh and tell us to point the person in the direction of a homeopath. Sitting in clinic for the first time I realised just what she meant as woman after woman sat down to realise that their acute problem was often their body’s way of expressing an underlying chronic issue.
With the exception of few acute situations such as shock, grief, having slipped, fallen, cut ones hand etc, the clinic deals indirectly with chronic illness by addressing the acute manifestation at the immediate presenting level. The initial 13 minute consultation consists of making quick judgements from information given and asking direct questions about if this acute issue could be influenced by something more bothersome. Instead of the open descriptive questions seen in a longer consultation, the acute clinic relies on confirmation, or not, of characteristics which may be integral to choosing the right remedy. For example a person will be directly asked if they are an obsessively tidy person in their home, who couldn’t leave a picture slightly slanted on a wall or some washing up in the sink to be done later. Their answer would then give indication that indeed arsenicum would fit the bill.
The structure of the clinic is such that advice is given to return in a month; however patients choose when to return and figures show that during 2006 roughly a quarter of patients did not return to clinic after their initial visit. Having worked with the clinic for 2 years I would say that this figure represents the amount of ‘true’ acute situations we deal with, leaving the remaining three quarters as evidence of underlying chronic conditions.
The following case example is indicative of many ‘acute’ cases taken at clinic and illustrates how underlying chronic conditions express themselves through acute symptoms.
Patient – 48 D
Initial Presenting Symptoms – sore throat
Sudden inflammation – burning and tingling with redness – dry throat makes swallowing difficult – worse at night
Remedy – Aconite 30c take as needed
Return 1 wk later
Remedy was effective but didn’t seem to hold as sore throat returned a couple of days ago. Took an average of 3x30c a day over a 3 day period. Has run out of remedy
Remedy – Aconite 30c in water taken twice daily
Return 2 wks later
Remedy has helped and sore throat has cleared. Patient informs us that during the past week she had to take part in a presentation through her volunteering skills program and had been very anxious about this. She reported that her anxiety had dissipated remarkably with the remedy and she presented feeling more confident.
This patient had known about her presentation before she developed a sore throat but had not seen the two as connected and therefore didn’t mentioned it at the initial consultation. She reports that she has always avoided public speaking in the past as it makes her anxious however she could not avoid it in this instance. After treatment she recalled suffering with sore throats as a child and when prompted to remember if they had come at times of anxiety she confirmed that this seemed to be the case. Consideration was given to the throat being an area which the body could express weakness in this case, especially with regard to the patient not being able to use her voice for her presentation.
Vithoulkas talks of acute illness as dominant over underlying chronic conditions which are effectively retired until the acute ailment has gone. I believe this to be true but not necessarily in the context delivered by Vithoulkas. The acute symptom is dominant at the time of case-taking but it can come as an expression of the chronic condition as it retires to a backseat. To deal with an acute illness Vithoulkas uses three sources of information detailed by Hahnemann in aphorism 84 of the Organon; the physical environment of the patient, the patient himself and information from family and friends to elicit a totality of symptoms for the acute situation alone. In the case given above, as with all cases at the clinic; the physical environment can only be offered by the patients narrative, and therefore may not contain all of the relevant data; information from family and friends is impossible; leaving only observation of the patient themselves and their symptoms upon which to prescribe.
In the acute clinic homeopaths have to use quick deduction to come up with the correct remedy in the first instance. This practice changes the more often the patient is seen due to the accumulation of more information over a period of time. Re-assessment of patients’ cases is an ongoing theme at the clinic and new information gathered is factored into the continued appropriateness of the originally selected remedy. The initial assessment and selection of a remedy evolves as the patient’s case unfolds, representing a journey through what is important for the patient at the time of each consultation. The remedy given deals with the presenting acute picture allowing this journey to reveal a little more of the patient’s overall picture at subsequent returns.
This unfolding of patients cases is very reminiscent of Eizayaga’s layers method of prescribing in which the local/legional layer is treated and remedy choice is not dependent upon more fundamental layers. Once the legional layer has been successfully prescribed upon, any underlying issues within the fundamental layer can be treated, and so on until the layer of constitution has been revealed. Once the layer of constitution has been revealed the clinics main aim is to raise vitality and maintain existing health over time.
The collated homeopathic drop-in attendance data shows that patients who attended clinic in 2004 are still attending clinic today. On the surface this phenomenon could be viewed as homeopathic care not proving successful due to the need for further returns over such a long period of time. However deeper analysis of how the clinic actually works reveals that these returning cases are evidence of a more chronic underlying issue for the patient. So when is an acute clinic chronic? In the case of the homeopathic drop-in clinic in the North East it could be argued that all situations are treated as acute to the patient at the time of presenting and help to form an ongoing chronic case-file about the patient over time.