New Methods: Need to evolve from “how-it-works” to “how-to-work with”

This paper was published in the January 2016 issue of Hpathy.

Genius, Sensation, Source and Periodic Table – Making it work

In the editorial of Hpathy Journal August 2015 issue, Alan Schmukler raised an excellent opportunity to explore the new emerging methodologies in Homeopathy, especially the Genius, Sensation, Source, Periodic Table and the like, collectively called the New Method in this essay.

Old wine …?

Some scholars consider the works mentioned as a clever spin on the Doctrine of Signatures(1)Little, David: The Compositae Family, The Three Kingdoms, http://www.simillimum.com/education/little-library/materia-medica/tcf/article.php, while some oppose the idea of limiting each remedy to one miasm (as redefined by the New Method). To such critics I would quote Aristotle who said, “It is the mark of an educated mind to be able to entertain a thought without accepting it”. That could provide us a good starting point for exploring these ideas.

Understanding the evolution of the Idea

To begin, one must understand that Sankaran has identified seven features that describe the Sensation – they are described as being Persistent, Primary, Permanent, Pattern, Pervading, Perpetual and Projecting. These features are considered to be global in scope or expression. The purists need not be too concerned, as this is really a re-statement of the principle of Generalities enunciated by von Bönninghausen, more than 150 years ago.

The second point to note is that miasms and sensations in the New Method were derived by analyzing and finding a sort of qualitative common denominator that ran through one family, by carrying out a search of rubrics using the MacRepertory. This was a novel application of the newly developed computerized repertorial tools made available at that time. But as all of us know, our Repertories derive from Materia Medicas, which derive from Provings, and Provings may not be complete. Furthermore, a lot can be lost in the process of this transmutation.

All computerized search engines are virtual statistical machines. The process of assigning causal associations to statistical groupings are purely a construct of the human mind, and there is no inherent “truth” that is revealed. For this reason Sankaran appropriately cautioned prospective users of the New Method that, “One should refrain from drawing any conclusions about the remedy without having reached the Level of Sensation”. This Level is to be perceived when the patient uses the so called Universal or Non-Human Specific language(2)Sankaran, Rajan: page 673 – The Sensation in Homeopathy, Homeopathic Medical Publishers, Santa Cruz, Mumbai, 2004.. Now this can be tricky – for example, how do we understand the statement, “It feels as if my joints are rusty and don’t have enough oil”? Is it a Delusion (an altered perception of reality) or is it a Non-human expression as the patient is talking about a “rusty joint”, as if it were a machine part? It may be argued either way, without helping much in adopting the Method, as the two interpretations will lead to different Levels, committing you on a different trajectory in search of the simillimum.

Understanding family resemblance

Regarding “Families”, the discerning practitioner must realize that even in personal life, members of the same family can be so different. It was Wittgenstein (1889-1951), the German philosopher, who had popularized the philosophical idea of “family resemblance”. He argued that things which may be thought to be connected by one essential common feature may in fact be connected by a series of overlapping similarities, where no single feature is common to all. Interestingly, Generality as defined by von Bönninghausen (1785-1864) comes close to this definition. Contrariwise, it has also been argued that members exhibiting family resemblance may share properties with each other, but have no properties that are singly necessary and jointly sufficient for family membership!

Let us take a look at Hahnemann’s views on family relationships. In his Lesser Writngs, he writes:

“But how can a similarity of action be expected amongst groups of plants, which are only arranged in the so-called natural system, on account of often slight external similarity, when even plants that are much more nearly connected, plants of one and the same genus, are sometimes so different in their medicinal effects”.

Understanding science

There is a lot of acrimony, debate, discussion and vilification that is happening in homeopathic discussion forums – one School pitted against another. That may be so because essentially philosophy like politics thrives on differences. But if we consider Homeopathy to be Science, then it would be a good idea to look at some ideas emerging from some contemporary science educators. One theme that is emerging is that of a “consensus approach”. According to this view, some points that are largely to be accepted are that, (1) scientific knowledge is empirical (i.e. relies on observation and experiment), (2) it is reliable but tentative (i.e., subject to change and thus never absolute), (3) partly the product of human imagination and creativity, and importantly, (4) theory-laden and subjective (i.e., influenced by beliefs, bias, culture etc.). Finally (5) there is no single scientific method that produces secure knowledge.

Indeed this may not be a complete or holistic view, but at the very least it opens us to the acceptance of new methodologies. How would we view “classical” Homeopathy and the New Methods in the light of these tenets? Consider tenets (1), (2), (3) and (5) above – could we consider the Banerji Protocols a logical evolution of Homeopathy? By the same token, the New Method should gain acceptance on the basis of tenet (1), (3), (4) and (5) above. But neither satisfy all the five criteria.

Understanding heuristics and limitations

Ultimately all methodologies in Homeopathy are heuristics; be they the Keynotes, Delusion, Miasm, Sensation, Periodic Table, Repertories and the like. Disease names, diagnosis and similar clinical labels are heuristic devices too – they help identify or categorize – to define taxonomy or an order of sorts. So let us not miss the woods for the trees – heuristics are neither the truth nor the science – they are tools that lead us on our path, like a map and a compass. To argue that this or that is “Not Homeopathy” is a limited view. Newtonian physics had to come to terms with Quantum Mechanics, but that does not make Newtonian physics irrelevant – it can still take us to the Moon, and beyond.

Medical Art is not a logical science, because what is logical is not always true. “Truth” in Medical Art is that which is seen, felt and experienced objectively as well as subjectively. Medical practice relies heavily on heuristics. However, the heuristic component of the reasoning process inherently encourages us to accept the conclusions we believe in, and reject the conclusions we don’t believe. So those of us, who have a belief in the New Method, will be inherently biased towards fitting the facts to the model. Thus, for one to assume that the New Method is the final resting place in our search for the simillimum would be a fallacy, because, each of these methodologies is just another piece in the multi-dimensional mosaic presented by the person in disease. Perhaps this is what prompted Hahnemann to underline the importance of the unprejudiced observer.

Understanding patterns

As humans, we have a brain that is constantly seeking patterns – that can either lead to superstition or science. Even superstitions have value in survival. A rustle in the grass can be just a current of wind, or it may be a snake. If the cost of believing a superstition is less than the cost of disbelieving it in the context of survival, then the superstition has value. In a life threatening situation – better superstitious than sorry!

Francis Bacon had observed, “Humanity has a proclivity to suppose the existence of more order and regularity in the world than it finds.” Patterns are perceived order from which we build concepts, but patterns are not concepts by themselves. That is why different individuals may conceptualize the same pattern in completely different ways. In his editorial Alan Schmukler has rightly pointed out that, “Sensation is a skill and discipline that requires much study and practice to master. As with all difficult tasks, some people are tempted to look for short cuts”. 

Paradoxically, the New Method was supposed to make the task of finding the simillimum more certain and more simple. This only means that there is more ground to cover. As Sankaran candidly admits, “I know that the Sensation idea holds true but I am not rigid about the approach of case-taking” (3)Sankaran, Rajan: page 25, The Synergy in Homeopathy, Homeopathic Medical Publishers, Santa Cruz, Mumbai, 2012, and further, “Sometimes I need to tell them that I do not fully believe in Sankaran!

How to Work with more important than How it Works?

In all fairness Sankaran has put in immense intellectual effort and his professional reputation at stake in developing a heuristic tool to deal with the fundamental problem of arriving at the simillimum. But clearly we are now well past the need of being convinced about its worth!  What is needed now is a collation of the integrated view. Dr. Bach (of Bowel Nosode and Bach Flower Remedies fame) was wont to destroy all copies of his older editions when new editions were published, so as to unburden the reader of the history of evolution of his method. Critical-mission industries like aviation archive all old publications and only allow access to the current version available for reference. Indeed reading through all of Sankaran’s works may prove to be an exciting journey for a student of the History of the New Method. What a practitioner needs is a precise, concise, crisp, and succinct crystallization of his ideas at one place.

Repertorization had fallen out of favor till the advent of computerized programs that integrated Materia Medicas, Repertories, Provings and a slew of homeopathic literature which allowed the practitioner to go beyond mechanical repertorization. Can the practitioner of today “leapfrog” the necessity of this heuristic tool which was ideally suited to an era when homeopathic software was available to too few, was too expensive and needed improvement. Today it is possible to form your own rubrics based on the actual language of the patient. In fact, the New Method was possible only because of these tools. So it is time this heuristic is formalized into a useable tool. The airplane invented by the Wright Brothers, was a contraption only they could fly. It was a few decades before it became a machine that could be handled by others too. The process has been perfected to the extent that we take the landing of an airplane with 500 souls on board, in unforgiving weather and zero visibility conditions to be just another routine, non-reportable event. Ask any aviator – every landing is as just unique and individual as each of our patients.

The New Method needs to graduate to that level, where successful cases are routine and rarely make it to seminars and conferences. At this point of time, we ought to have a simple way to work with the New Method, rather than knowing How it Works.

Overcoming our hemispheric asymmetry

To work effectively with his Method, Sankaran has pointed out that in perceiving a case, the left and the right brain both need to be active, because you are getting both conceptual as well as factual information. That may appear to be a tall order, but it can be achieved, only if the student of homeopathy moves out of the confines of a rigid strait jacket of logical science and dons the mantle of humanities as well. Only with practice and training can the two halves of the brain be harnessed. Is that achievable? Is the Method replicable? I think we ought to take a serious look at what we teach our students. Is it the educational foundation and the primary outlook of our practitioners that needs some improvement?

Healing and Humanities go together

To begin with, the reader is requested to peruse through the syllabus of a Central Council of Homeopathy approved BHMS program at a typical Homeopathic Medical College in India(4)BHMS syllabus: CMP Homeopathic Medical Collegehttp://www.homeopathyinstitute.in/pdf/bhms_all_17082012_1402.pdf. In the rigorous 4 year course (followed by one and a half years of clinical internship), the subjects covered include Anatomy, Physiology, Biochemistry, Materia Medica, Organon, Pathology, Parasitology, Forensic Medicine, Toxicology, Microbiology, Surgery, and only in the Final Year, Repertory and Case Taking. Out of a maximum total of 4,400 marks that can be scored over 4 years, the Repertory and Case taking are worth only 200 marks (approx. 4.5 % only).

Shouldn’t Homeopathic education include subjects like History of Science, a short course in Philosophy, some exposure to appreciation of Literature, and a methodical approach to inquiry and discussion to promote critical thinking through dialectics? A report on nursing education in the US revealed that the majority of nursing programs (77%) include content and/or experiential learning in complementary health and healing in the curriculum. A wide range of content related to mind-body healing, alternative medicine, herbal supplements, manual and energy healing, and environmental modalities is included(5)Richardson SF: Complementary health and healing in nursing education, Journal of Holistic Nursing 2003, March. If we seek acceptance from the allopathic school, shouldn’t we educate ourselves with supportive methodologies in healing? This will not only widen the intellectual horizon of young entrants in our profession, but also equip them to bear the brunt of assault from pharmaceutical industry and allopathy. All this must be viewed in context – students who enter a Homeopathic Medical School (in India) are typically 17-19 year olds, and their last brush with subjects related to Humanities has been at Year 10 of High School (ages 15-16 years). How can we expect our budding homeopaths to at the very least, “entertain without accepting” the ideas of Scholten and Sankaran, or appreciate Vermuelen’s rich Arcana of Materia Medica, without a dialectic examination of mythology, ethno-medicine, even astrology?

US Medical Schools respect for Humanities

Compare this with medical school admission requirements in the US. Most schools clearly state that aspiring entrants must, “demonstrate aptitude in the biological and physical sciences during their undergraduate years, but not to the exclusion of the humanities and social sciences. No preference is given to applicants who have majored in the sciences over those who have majored in the humanities(6)Harvard Medical School: Requirements for Admission https://hms.harvard.edu/departments/admissions/applying/requirements-admission. Indeed, the subject of medical humanities lies at the intersection of medicine and humanistic disciplines such as philosophy, religion, literature, and the fine and performing arts. According to a 2012 study published by the Association of American Medical Colleges, such disciplines inculcate compassion and empathy alongside science and data, and there is evidence that humanities lessons may be linked to better disease outcomes, too(7)Association of American Medical Colleges: https://www.aamc.org/newsroom/reporter/may2014/380438/humanities.html. Most students described the humanities program as “the tether that helped them reconnect and hold on to the reasons they wanted to become a doctor in the first place”. Is it unreasonable to believe that these shortcomings do not affect the outcomes of our practitioners?

Conclusions

In conclusion I would like to state that we are now well past the stage of debating whether or not the concepts of Genius, Sensation, Periodic Table, Source etc., are valid. We need to move beyond exhibitions, seminars, and workshops, and instead deliver a workable tool for use in the consulting room. What Repertories did more than a hundred years ago, we need to do that for the New Method. If James Tyler Kent (1849-1916) could do it on his desk with a paper and pen, a 100 years ago, with virtually no institutional or community support, our 21st century situation should make it possible sooner than later.

 

References   [ + ]

1. Little, David: The Compositae Family, The Three Kingdoms, http://www.simillimum.com/education/little-library/materia-medica/tcf/article.php
2. Sankaran, Rajan: page 673 – The Sensation in Homeopathy, Homeopathic Medical Publishers, Santa Cruz, Mumbai, 2004.
3. Sankaran, Rajan: page 25, The Synergy in Homeopathy, Homeopathic Medical Publishers, Santa Cruz, Mumbai, 2012
4. BHMS syllabus: CMP Homeopathic Medical Collegehttp://www.homeopathyinstitute.in/pdf/bhms_all_17082012_1402.pdf
5. Richardson SF: Complementary health and healing in nursing education, Journal of Holistic Nursing 2003, March
6. Harvard Medical School: Requirements for Admission https://hms.harvard.edu/departments/admissions/applying/requirements-admission
7. Association of American Medical Colleges: https://www.aamc.org/newsroom/reporter/may2014/380438/humanities.html

A blocked nose – pathogenesis and pathophysiology

This article was originally published by Homeopathy4you (http://hpathy.com/clinical-cases/follow-your-nose-a-lesson-in-pathogenesis-and-pathophysiology/)

Pathogenesis, pathophysiology and symptomatology

A clear understanding of pathogenesis, pathophysiology and symptomatology goes a long way in understanding and solving a case. Pathogenesis is a chain of biological mechanisms that leads to the diseased state. Pathophysiology refers to the functional changes resulting from disease. Symptomatology refers to the set of symptoms characteristic of a medical condition. What lies beyond these are the characteristics of the person in a state of disease – what we call as the individualizing factors. To find the simillimum we must find a match that covers this entire spectrum. Let us take the example of a stuffy nose.

A stuffy nose affects the quality of life

A blocked nose is a very common symptom encountered by a large number of people. It is described subjectively as fullness, obstruction, reduced airflow, being “stuffed up”, or “stopped up”. It is often the predominant symptom in disorders such as allergic rhinitis, rhinosinusitis, non-allergic rhinitis, and nasal polyposis. Nasal congestion is also a common symptom in middle ear infection (otitis media) and asthma. It can lead sleep disturbances, including instances of shallow or infrequent breathing during sleep (obstructive sleep apnea) which can be life threatening.

A blocked nose can have a significant impact on quality of life in terms of emotional function, loss of productivity, and the ability to perform even routine daily activities comfortably (1)Shedden A: Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey. Treatments in Respiratory Medicine 2005;4(6):439-46. A blocked nose comes with a heavy price tag – it has an economic impact. Surveys in the US indicate that in the year 2004 rhinosinusitis alone affected tens of millions of people and led to an expenditure of approximately $6 billion in overall health care (2)Leggett JE: Acute sinusitis. When – and when not – to prescribe antibiotics. Postgrad Med. 2004;115(1):13–19.

Perception and Pathology

Nasal congestion is defined as a perception of reduced nasal airflow or a sense of facial fullness, and it can involve a number of underlying mechanisms. For example, inhaling mentholated vapors activates the cold receptors in the nasal passage and this cool sensation creates the impression of increased airflow without actually altering airflow (3)Eccles R. Menthol: Effects on nasal sensation of airflow and the drive to breathe. Curr Allergy Asthma Rep. 2003;3(3):210–214. Conversely, patients with complete turbinectomy (“empty nose”) may still complain of the perception of nasal congestion (4)Naclerio RM, Bachert C, and Baraniuk JN: Pathophysiology of nasal congestion, International Journal of General Medicine 2010:3 47–57.

Nasal congestion usually starts with an irritation triggered by an allergen or an infection of the mucosal membrane in the nasal passage which results in an inflammatory response. This response involves increased congestion of veins, increased nasal secretions, and consequently a swelling of the related tissues. This leads to physical problems affecting the structure of the nasal passage; and affects sensory perception. Advances in medical technology like rhinomanometry and acoustic rhinometry, have made it possible to qualitatively and quantitatively study the nasal airways, and have provided greater insight in understanding this more-than-irritating symptom (5)Corey JP, Houser SM, Ng BA: Nasal congestion – a review of its etiology, evaluation, and treatment. Ear Nose Throat J. 2000; 79(9):690–698. In a typical episode of allergic rhinitis or rhinosinusitis the physical size of the nasal passages is reduced due to widening of blood vessels (vasodialation). These effects result in increased blood flow and consequent increase in the flow of cells responsible for immune response (lymphocytes) moving across the walls of the blood vessels (increased vascular permeability). This causes swollen tissues inside the nose that cause obstruction of nasal airflow, ultimately contributing to nasal congestion. These swollen tissues can also cause blockage of the drainage pathways of sinuses.

But it’s not just germs and allergens

A blocked nose is not necessarily the consequence of allergic rhinitis or rhinosinusitis. It has been found that all these effects can be produced through the central nervous system (neural mechanisms) without any demonstrable mucosal abnormality. This is so because the nose is armed with a complex nervous system that includes sensory, sympathetic, and parasympathetic nerves. It is also known that emotions can trigger physiological responses that are regulated by the brain (6)Dirk Hagemann , Shari R. Waldstein, Julian F. Thayer: Central and autonomic nervous system integration in emotion, Brain and Cognition, volume 52, issue 1, June 2003, p. 78-79. Thus the constellation of symptoms that we see in rhinitis can also be triggered emotionally. It is also interesting to note that neural activity in the nose can influence physiology in another part of the body as well, typically in the bronchial tree and the cardiovascular system. Such an exaggerated physiological response is called neural hyper-responsiveness, which is not yet fully understood (7)Sarin S, Undem B, Sanico A, Togias A: The role of the nervous system in rhinitis. Journal of Allergy and Clinical Immunology 2006 Nov;118(5):999-1016.

Hypertension and the stuffed nose

Research indicates that there is an association between impaired respiratory function and hypertension. Hypertension is found to be more frequent in men with rhinitis than in men without rhinitis (even after adjustment for major known confounding factors). Hence it is recommended that blood pressure should be regularly checked in men with rhinitis. However researchers admit that the physiopathological mechanisms underlying these associations are not known (8)Sabine Kony, Mahmoud Zureik, Catherine Neukirch, Bénédicte Leynaert, Daniel Vervloet, andFrançoise Neukirch: “Rhinitis Is Associated with Increased Systolic Blood Pressure in Men”, American Journal of Respiratory and Critical Care Medicine, Vol. 167, No. 4 (2003), pp. 538-543.doi: 10.1164/rccm.200208-851O. In what would be a corollary to these findings, research seems to suggest that treatment of allergic rhinitis can improve blood pressure (9)Magen E, Yosefy C, Viskoper RJ, Mishal J: Treatment of allergic rhinitis can improve blood pressure control. Journal of  Human Hypertension 2006 Nov;20(11):888-93. Epub 2006 Sep 7.

Decongestants and blood pressure

The paradoxical situation one faces is that most allopathic decongestants you would like to use to improve your quality of life are contraindicated if you have high blood pressure. Typically these drugs are oral nasal decongestants such as pseudoephedrine and phenylephedrine; topical nasal decongestants, such as  oxymetazoline,  phenylephrine,  naphazoline; and the Vicks Vapor Inhaler (l- desoxyephedrine/ levmetamfetamine); topical hemorrhoid products; asthma alleviating products containing ephedrine, aspirin; and NSAIDS, such as ibuprofen.

A homeopathic case

The author dealt with a case of a 60 year old male who was in a good state of health and was not taking any medications for any chronic complaints. He had a history of persistent stuffy nose. It would start with an episode of non-allergic rhinitis. He felt it was caused by stress as he could not associate any particular allergen (like dust, pollen, food etc) with this complaint. He would suffer such an attack two to three times a year. The attack of rhinitis would be followed by nasal congestion and then it seemed that the catarrhal condition had “fallen” into the chest. Recently he had relocated to a new home in a new city, so there was latent stress due to these changed circumstances.

When he consulted me I used the following rubrics (after combining):

COUGH – ASTHMATIC etc…:

MIND – Dreams of death, dying, dead people etc…:

RESPIRATORY SYSTEM – Expectoration – Viscid, tenacious, difficult of raising etc… etc…:

NOSE – SNEEZING – violent etc…:

NOSE – Obstructed etc…:

CONDITIONS OF AGGRAVATION AND AMELIORATION IN GENERAL – Coition – after – agg. etc…:

The top remedies were kali-c, kali-bi, nux-v, carb-v, lyc, anac.

He also reported an aggravation at 3 am in the morning and around 8 pm evening. Kali-c, nux-v and lyc were the leaders. Given the affinity of Kali salts to the mucosal membranes the choice was kali-c.

The patient did quite well on kali-c 30, and in a follow-up after 3 weeks he was free from all the symptoms. Interestingly he said that he had a long standing complaint of dandruff which also seemed to have vanished. However, two months later he came back again with the same symptoms (minus the dandruff). Kali-c 30 was repeated but the symptoms showed only a slight improvement, and only worsened after a week. Nux-v was next considered as it figured quite prominently in the repertorial analysis. But that did not help. In fact the patient has to use Otrivin nasal spray (xylometazoline) for symptomatic relief.

Search for an intercurrent remedy

During this period he underwent a routine medical screening for renewal of a health insurance policy which included an ECG, a chest X-Ray, lipid profile, creatinine/ urine analysis and blood sugar checkup. While these test returned normal values, the blood pressure was noted to be very high -210/100 mmHg. The patient had been asymptomatic for any cardiovascular complaints and was not taking any medication for blood pressure control and was keen not to take any medication on a life-long basis. He preferred to take homeopathic treatment only.

In view of his medical reports, the author considered an intercurrent remedy – Rauwolfia serpentine, a remedy known quite well to herbalists as well as homeopaths. It was the first allopathic drug to be introduced specifically for hypertension (10)Vakil RJ: A Clinical Trial of Rauwolfia Serpentina in Essential Hypertension; British Heart Journal 1949;11:4 350-355doi:10.1136/hrt.11.4.350. It was a major breakthrough in therapeutics. Efforts were made by the pharmaceutical industry to extract and identify the active ingredient and synthesize the same for clinical use. Reserpine was identified as the active ingredient and introduced in the market. However, very soon both the drugs fell out of favor due to reported side effects. Among the side effects reported for these drugs were: dry mouth, stuffy nose, nasal polyps, loss of appetite, reduced desire for sexual intercourse, diarrhea, and abnormal heart rhythm. There have also been reports of psychiatric symptoms like depression and suicidal tendencies, restlessness, and insomnia. Rauwolfia was added to the homeopathic repertorium after Templeton’s provings in 1955. The proving symptoms replicated the “side-effects” reported by allopathic users of the same drug, in particular the concomitants of stuffed nose and elevated blood pressure.

The patient was prescribed Rauw. MT, and Crataegus MT, 5 drops, three times a day. Blood pressure was checked after 10 days and was found to be 145/90 mmHg. The patient was impressed with this remarkable effect on his blood pressure values. Subsequently he monitored blood pressure on a daily basis (mornings and evenings) and he found a steady improvement as it settled between systolic 125-130 mmHg and diastolic 70-90 mmHg.

But the stuffy nose did not improve and he had to revert to the use of the nasal spray. He also reported dryness of the mouth. At this point the author considered using Rauw in potentized form and selected 6C potency in medicated pill form – 2 pills twice daily. Crataegus MT  was discontinued. Within a week the stuffy nose cleared up gradually and he discontinued the use of xylometazoline nasal spray completely.

It is interesting to note that Rauw has obstruction of nose (chronic), dryness of mouth, sneezing, sleep disturbance at 3 am, 8 pm aggravation, cough aggravated by lying down, diminished sexual libido, and dreams of dying, dead people and death (11)Stephenson J: Materia Medica and Repertory 1924-1959. Proving of Rauwolfia serpentina. However, Rauw is a small remedy and will not show up in a repertorial search for rhinitis-like complaints. But an understanding of the connection between hypertension and swollen turbinates in the nasal passage and its relationship to the proving symptoms and clinical symptoms of Rauw made it possible to help the case.

The way ahead

The patient has been symptom free for a few months, but the author has asked the patient to follow-up with a session to work out a “constitutional” remedy to prevent acute manifestations of an underlying chronic condition. It is interesting to note that Rauw is associated with the increased Morg-g in stool cultures. Since the patient is symptom free and not on any medication, perhaps a dose of bowel nosode Morg-g could help give a clearer picture?

The case showed that an understanding of the pathogenesis, pathophysiology and symptomatology in a case can help us to form a clearer picture of the totality. The author is grateful to Dr. Sunirmal Sarkar of Kolkata for the guidance provided by his book on clinical approaches (12)Sarkar Dr. S: Just You See, Homoeopathic Medical Publishers, Mumbai, 2013.

References   [ + ]

1. Shedden A: Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey. Treatments in Respiratory Medicine 2005;4(6):439-46
2. Leggett JE: Acute sinusitis. When – and when not – to prescribe antibiotics. Postgrad Med. 2004;115(1):13–19
3. Eccles R. Menthol: Effects on nasal sensation of airflow and the drive to breathe. Curr Allergy Asthma Rep. 2003;3(3):210–214
4. Naclerio RM, Bachert C, and Baraniuk JN: Pathophysiology of nasal congestion, International Journal of General Medicine 2010:3 47–57
5. Corey JP, Houser SM, Ng BA: Nasal congestion – a review of its etiology, evaluation, and treatment. Ear Nose Throat J. 2000; 79(9):690–698
6. Dirk Hagemann , Shari R. Waldstein, Julian F. Thayer: Central and autonomic nervous system integration in emotion, Brain and Cognition, volume 52, issue 1, June 2003, p. 78-79
7. Sarin S, Undem B, Sanico A, Togias A: The role of the nervous system in rhinitis. Journal of Allergy and Clinical Immunology 2006 Nov;118(5):999-1016
8. Sabine Kony, Mahmoud Zureik, Catherine Neukirch, Bénédicte Leynaert, Daniel Vervloet, andFrançoise Neukirch: “Rhinitis Is Associated with Increased Systolic Blood Pressure in Men”, American Journal of Respiratory and Critical Care Medicine, Vol. 167, No. 4 (2003), pp. 538-543.doi: 10.1164/rccm.200208-851O
9. Magen E, Yosefy C, Viskoper RJ, Mishal J: Treatment of allergic rhinitis can improve blood pressure control. Journal of  Human Hypertension 2006 Nov;20(11):888-93. Epub 2006 Sep 7
10. Vakil RJ: A Clinical Trial of Rauwolfia Serpentina in Essential Hypertension; British Heart Journal 1949;11:4 350-355doi:10.1136/hrt.11.4.350
11. Stephenson J: Materia Medica and Repertory 1924-1959. Proving of Rauwolfia serpentina
12. Sarkar Dr. S: Just You See, Homoeopathic Medical Publishers, Mumbai, 2013

Cough and the common cold

Cold and cough are the two most common issues faced by those treating children. It is more common in preschool children than in older children(1) Morrell DC. Symptom interpretation in general practice. Journal of the Royal College of General Practice 1972; 22(118):297–309. Acute cough is most commonly associated with the common cold. The Association of American Family Physicians recommends that if the cough is due to the common cold, a first-generation antihistamine plus a decongestant should be prescribed. It has been shown that naproxen favorably affects cough. Newer-generation non-sedating antihistamines are not effective for reducing cough(2)Coughlin L: American Family Physician, 2007 Feb 15;75(4):567-575.

Expected Recovery Time

Both doctors and parents tend to underestimate recovery times. Most believe that uncomplicated coughs will resolve in two weeks. Prospective cohort studies have found that only 50% of children with coughs recovered in 10 days, while 10% of children were still coughing at 25 days(3)Hay AD, Wilson A, Fahey T, Peters TJ. The duration of acute cough in pre-school children: a prospective cohort study. Fam Pract. 2003;20(6):696–705. Several studies have also revealed another interesting finding – if the parent expects to receive an antibiotic prescription, or the physician believes that the parent expects one, there is an increased likelihood that such a prescription will be written. On the other hand, if the parent thinks the child has a viral respiratory tract infection, the child is only half as likely to receive antibiotics(4)Vinson DC, Lutz LJ: The effect of parental expectations on treatment of children with cough: a report from ASPN. J Fam Pract. 1993;37(1):23–7.

The Use and Uselessness of Antibiotics

These unrealistic expectations often lead doctors and parents to use antibiotics. Although warranted in some cases, antibiotics are greatly overused. The American Academy of Family Physician (AAFP) cautions that one should remember that common cold is a mild, self-limited upper respiratory tract infection with symptoms of runny nose, sore throat, cough, sneezing, and nasal congestion. It is a heterogeneous group of viral diseases, and therefore does not respond to antibiotics. AAFP does not recommend use of antibiotics for acute bronchitis and tracheitis, acute rhinosinusitis, common cold, laryngitis or influenza(5)Zoorob R et al: American Family Physician, Volume 86, Number 9, November 1, 2012.

Research studies point to the fact that antibiotics have no effect on viral infections; indeed they might cause side effects that are more distressing than the cough. Most parents will not be too concerned about increasing antibiotic resistance; however, most should be told that antibiotics are at least as likely to cause side effects as they are to produce improvement in their children. They should also be told that serious adverse events and accidental poisonings have been recorded in children from exposures to over-the-counter medications(6)Gunn VL, Taha SH, Liebelt EL, Serwint JR: Toxicity of over-the-counter cough and cold medicines.Pediatrics. 2001;108(3):E52 .

It has been found that mostly, acute coughs in children are due to acute viral infections (common colds, acute bronchitis, croup, and influenza). Although children are far less likely to be suffering from the chronic respiratory and cardiac conditions that affect some adults, acute cough can be indicative of conditions that the physician should not miss, such as asthma, bronchiolitis, whooping cough, pneumonia, and foreign body aspiration.

Alarm signs

If the child looks ill (with pneumonia or influenza) or is short of breath with tachypnea (with asthma or foreign body aspiration), or, the child is working hard to breathe (perhaps with chest retractions) – there is cause for alarm. There might be a high fever (with pneumonia, but some children can run sudden high fevers with otherwise innocuous viral infections). Therefore, parents must look out for fast breathing, chest retractions, and wheezing as danger signs. This is so because children with neither fever nor chest signs had a probability of complications of only 6%, for children with chest signs it was 18%, with fever it was 28%, and when both fever and chest signs were present the probability was 40%(7)Hay AD, Fahey T, Peters TJ, Wilson A: Predicting complications from acute cough in pre-school children in primary care: a prospective cohort study. Br J Gen Pract. 2004;54(498):9–14.

A Homeopathic perspective

In addition to understanding the physiological and pathological findings with regards to the cough, a homeopathic approach requires collection of all subjective symptoms – in other words, a narrative of how the complaint is felt and perceived by the sick person. Symptoms are the person’s individual response to the disease. That is why those symptoms which are peculiar or typical to named disease will score lower in the hierarchy of importance in the selection the remedy.

Such details include, for example, what are the sounds – wheezy, hacking, croaking; does the cough come in paroxysms, and if so, how many paroxysms; is it violent, gagging, leads to vomiting, or is it hollow, dry, incessant. The next important point to know is when do we see an aggravation – is it cold breeze, night, day, lying down, sitting, climbing stairs etc. that make the person feel worse. What makes the person feel better – is it warmth, fanning cold air, lying down etc. What are the changes in the demeanor and temperament – is the person averse to noise, company, or desires caressing and clinging? Also, what else is going on with the cough – is there pain in the abdomen, sweat on hands, feet or forehead. Also observations like the person bending over, stamping feet etc. The pace and onset of the disease is also relevant – was the onset slow, over a few days, or was it sudden. Changes in mood and attitude are of great importance too.These facts are important because they help us to complete the portrait of the remedy required.

The next important thing is to have a close follow-up – you must report any changes to the symptom picture as that will help the homeopath to give remedies that follow well or which compliment the first remedy.

Research points to effectiveness of homeopathy in helping treat cold and cough(8)Cucherat M, Haugh MC, Gooch M, Boissel J-P: Evidence of clinical efficacy of homeopathy-European Journal of Clinical Pharmacology, April 2000, Volume 56, Issue 1, pp 27-33.

References   [ + ]

1.  Morrell DC. Symptom interpretation in general practice. Journal of the Royal College of General Practice 1972; 22(118):297–309
2. Coughlin L: American Family Physician, 2007 Feb 15;75(4):567-575
3. Hay AD, Wilson A, Fahey T, Peters TJ. The duration of acute cough in pre-school children: a prospective cohort study. Fam Pract. 2003;20(6):696–705
4. Vinson DC, Lutz LJ: The effect of parental expectations on treatment of children with cough: a report from ASPN. J Fam Pract. 1993;37(1):23–7
5. Zoorob R et al: American Family Physician, Volume 86, Number 9, November 1, 2012
6. Gunn VL, Taha SH, Liebelt EL, Serwint JR: Toxicity of over-the-counter cough and cold medicines.Pediatrics. 2001;108(3):E52 
7. Hay AD, Fahey T, Peters TJ, Wilson A: Predicting complications from acute cough in pre-school children in primary care: a prospective cohort study. Br J Gen Pract. 2004;54(498):9–14
8. Cucherat M, Haugh MC, Gooch M, Boissel J-P: Evidence of clinical efficacy of homeopathy-European Journal of Clinical Pharmacology, April 2000, Volume 56, Issue 1, pp 27-33

An Integrated Approach to Manage Hypertension

What is Essential Hypertension?

Essential hypertension is the condition normally known as high blood pressure in adults where there’s no identifiable cause of high blood pressure.  Such a condition develops over a long period of time. Essential hypertension accounts for 95% of all cases of hypertension. Some people have high blood pressure caused by an underlying condition, such as kidney problems, adrenal gland tumors, thyroid problems, congenital defects or due to effects of certain types of medications like cold remedies, decongestants, alcohol abuse or drugs like cocaine or amphetamines(1)http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/causes/con-20019580. This type of high blood pressure is called secondary hypertension and tends to appear suddenly.

Complications of high blood pressure (from Wikimedia Commons)

Complications of high blood pressure (from Wikimedia Commons)

In industrialized societies, the risk of becoming hypertensive (blood pressure >140/90 mm Hg) during a lifetime exceeds 90%. According to the National Heart, Lung and Blood Institute, hypertension (high blood pressure) usually neither causes pains nor causes complaints(2)http://www.nhlbi.nih.gov/health/health-topics/topics/hbp/signs#However, modern medicine has discovered that hypertension was found as the preceding condition in cardiovascular events like heart attack, stroke, embolism, kidney failure and more. Therefore, medical research was directed to search for medication that forced the body to lower its blood pressure.

Body’s natural response

It must be first understood that high blood pressure is a logical response of our body’s intelligent control system. A reduction of blood flow (due to narrowed blood vessels and/or increased viscosity of blood) will lead to a deficiency of oxygen and energy to the cells and organs. To overcome this, our body elevates the blood pressure to maintain a sufficient supply of oxygen and energy to the cells and organs of the body. Drugs that are used to reduce the blood pressure do not overcome the circumstances that are causing the higher resistance to the flow of blood. On the contrary, they work against the efforts of our body to maintain a sufficient supply of oxygen and energy, in spite of harder circumstances. That’s why one feels worse when taking those pills. The pills can’t cure your high blood pressure. But they do cause the so-called “side-effects”, namely, dizziness, headache, fatigue, depression, throbbing of the heart, lack of energy, lack of concentration, impotency, frigidity and more.

Overdiagnosis and Overmedication?

Let us consider some facts. Sixty percent of ALL the most prescribed medications are for hypertension, high cholesterol levels, and diabetes(3)Herper M: America’s most popular drugs: a narcotic painkiller tops Forbes’ list of the most prescribed medicines. ForbesMay 11, 2010. What could be the possible reasons that explain such a dramatic rise in the diagnosis and treatment of these chronic conditions? One important factor is the pronounced lowering of diagnostic thresholds for diabetes and hypertension. As a result of lowering the bar, millions of people previously defined as healthy now are classified as needing treatment(4)Welch HG, Schwartz LM, & Woloshin S: Overdiagnosed: Making People Sick in the Pursuit of HealthBoston, MA: Beacon Press; 2011:171–172.. Lower diagnostic thresholds have resulted in large increases in the number of candidates for treatment, with an estimated 22 million additional people in the US alone being treated for hypertension(5)Yoon SS, Ostchega Y, & Louis T: Recent trends in the prevalence of high blood pressure and its treatment and control, 1999–2008. NCHS Data Brief. 2010;Oct(48):1–8.. Till the year 1992, for non-diabetic persons, the threshold for hypertension diagnosis was accepted as 160/95 mmHg. In the year 1993 this limit was reduced to 140/90 mmHg(6)Hunt LM, Kreiner M, & Howard Brody H: The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes, Annals of Family Medicine, September/October 2012 vol. 10 no. 5 452-460 .

According to the American Heart Association, “There is no specific level of BP where cardiovascular and renal complications start to occur; thus the definition of hypertension is arbitrary, but needed for practical reasons in patient assessment and treatment”(7) Carretero OA, MD & Oparil S: Clinical Cardiology, Essential Hypertension, American Heart Association publication – Circulation.2000; 101: 329-335.

Understanding the physiology in the search for drugs

Physiology of blood pressure regulation

Physiology of blood pressure regulation (From Wikimedia Commons)

The study of the physiology of blood pressure control and regulation can be both illuminating as well as frustratingly confusing. It is illuminating because it reveals that blood pressure regulation is not simply a complicated homeostatic control loop. It is frustratingly confusing because it is a complex responsive process that involves pressure receptors working with parts of the brain that act on the autonomous nervous system; the liver-kidney-adrenal-lung complex that involves various hormones and enzyme reactions that affect the blood vessels, heart output, water/ sodium excretion, calcium and potassium balance and a host of other mechanisms that are till today poorly understood.

The response of the pharmaceutical industry has been to produce a class of drugs to address the parts that constitute the whole picture. The most commonly used drugs for hypertension include the thiazide diuretics, beta-blockers, ACE inhibitors, angiotensin II receptors antagonists, calcium channel blockers, alpha-adrenoceptor blockers, combined α- and β-blockers, direct vasodilators, and some centrally acting drugs such as α2-adrenoceptor agonists and imidazoline I1 receptor agonists. This piecemeal approach leaves the patient with as many as five or more prescriptions to keep the numbers low. Medical researchers admit that “Hypertension is one common disease that can be challenging to treat in the elderly due to the body’s physiologic changes, potential risks for side effects, medication interactions, and decreased medication adherence.(8)Cooney D, Pascuzzi K: Polypharmacy in the elderly: focus on drug interactions and adherence in hypertension. Clin Geriatr Med. 2009 May;25(2):221-33. doi: 10.1016/j.cger.2009.01.005

Have the drugs helped?

One would be led to believe that with the detailed knowledge of the mechanics of our body and the billions spent on development of drugs, we are in a better situation today than the late US President Woodrow Wilson was, when he supposedly died due to the effects of severe hypertension at a time when there were no medicines available for controlling high BP.

A recent research published by Cochrane reviewed 8,912 participants with mildly elevated blood pressures (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg), but no previous cardiovascular events and who were under treatment for 4 to 5 years with anti-hypertensive drugs. The startling truth they revealed was that compared to the results obtained with placebo, the drugs did not reduce total mortality. In 7,080 participants treatment with antihypertensive drugs as compared to placebo did not reduce coronary heart disease, stroke or total cardiovascular events. In fact withdrawals due to adverse effects were increased by drug therapy and absolute risk increase was 9%(9)Diao D, Wright JM, Cundiff DK, Gueyffier F: Intervention Review – Pharmacotherapy for mild hypertension,  The Cochrane Collaboration published in The Cochrane Library 2012, Issue 8.

The 2014 report from the Eighth Joint National Committee for Evidence-Based Guideline Management of High Blood Pressure in Adults has defined new limits for defining hypertension(10)Journal of the American Medical Association: JAMA 2014;311(5):507-520. doi:10.1001/jama.2013.284427.  Accordingly, non-diabetic persons and persons not suffering from chronic kidney disease aged 60 years or older a BP goal of less than 150/90 mm Hg is recommended (previously it was 140/90 mmHg for this population). They also mentioned that lifestyle treatments have the potential to improve BP control and reduce medication needs.

An integrative approach can help

Hippocrates had written that disease was both pathos (suffering) and ponos (toil), as the body worked to restore normalcy. The reason modern medicine has only concentrated on the toil is because fever, BP, sugar levels are measureable, while suffering is individual and internal. Raising blood pressure is the natural, intelligent, function of the body to cope with circumstances. But what could cause a permanent reset of the regulation system to a higher value of regulate blood pressure as it happens in essential hypertension? Why would the body move away from the best value for blood pressure?

Perhaps the answer can be found in the work of Dr. Hans Selye. Selye postulated that sickness was an adaptive response. For example, a fever that raises the core body temperature by 1 degree Celsius, costs the body an additional 13% energy. Suppressing a fever may save this additional expenditure, but the organism will fail in fighting off infection and may eventually die. However, to conserve this additional burden the body brings about behavioral changes such as huddling, making postural changes and seeking shelter. These are the subjective symptoms which are of little value in allopathic practice.

Selye coined the term syndrome of being sick to describe this stage of coping. This is the closest that one can come to explain the importance Homeopathy places on symptoms and sensations described by the patient. They go beyond the objective signs that laboratory tests will ever reveal. A practitioner of Homeopathy and Bach Flower Therapy is looking for these subjective symptoms to find a remedy. In the example given above, the fever is the objective symptom – the ponos described by Hippocrates. The description of pain, the amelioration caused by postural adjustment, the craving for warm drinks and aversions to cold drafts of air are part of pathos. How can we ever expect to find a remedy without taking pathos and ponos into account together?

Lifestyle is the key

Nearly 200 years before the dawn of the “New Age”, Dr. Samuel Hahnemann, the founder of Homeopathy, emphasized that life-style modification is the first step in the treatment of any disease or disorder. His instructions were strict – no spices, salt, tea, coffee, or alcohol and he advocated pure food grown as close to nature as possible. He stressed on the importance of moderate exercise, but most of all it was the removal of stressful factors and getting adequate rest that was necessary.

It has taken two centuries for modern medicine acknowledge that more than medicine, “A reduced fat, low cholesterol diet that emphasizes fruits, vegetables and low fat dairy products, and maintains an adequate intake of potassium, magnesium and calcium, should be followed; salt intake should be restricted; and stress management should be considered as an intervention”(11) Touyz RM, Campbell N, Logan A, Gledhill N, Petrella R, Padwal R: The 2004 Canadian recommendations for the management of hypertension: Part III–Lifestyle modifications to prevent and control hypertension, The Canadian Journal of Cardiology [2004, 20(1):55-59].

An eighteen month randomized clinical trial(12)Wang YF , Yancy Jr WS, Yu D ,  Champagne C , Appel LJ and Lin PH: The relationship between dietary protein intake and blood pressure: results from the PREMIER study – Journal of Human Hypertension (2008) 22, 745–754 and an epidemiological study with a 8-year follow-up(13)Stamler J, Liu K, Ruth KJ, Pryer J, Greenland P. Eight-year blood pressure change in middle-aged men: relationship to multiple nutrients.Hypertension 2002; 39: 1000–1006 confirmed that an increased intake of plant protein may be useful as a means to prevent and treat hypertension.

Numerous studies have also confirmed that giving up smoking, and refraining from consumption of alcohol have major beneficial effects on reducing BP(14)Dickey RA, Janick JJ: Lifestyle Modifications In The Prevention And Treatment Of Hypertension, Endocrine Practice, Volume 7, Number 5/September/October 2001.

Regulation of blood pressure requires the pituitary-heart-lung­-kidney-adrenal mechanism to be kept in good working order. This can be best achieved by seeking a holistic, integrated approach.

Perhaps only homeopathy has remedies that address stress causing factors. For example there are remedies that will specifically take into account agitation, resentment, fear, anxiety, grief or anger if that forms part of the symptom portrait. When we combine meditation and creative visualization along with homeopathic treatment, your primary care physician will notice the steady improvement and that may result in reduced drug uptake. It must be mentioned though, Blood pressure can be more difficult to treat if drugs are used as well. Homeopathy works but it can take longer.

Practices to managing stress

Research in modern medicine now confirms that stress can cause hypertension through repeated blood pressure elevations as well as by stimulation of the nervous system to produce large amounts of vasoconstricting hormones that increase blood pressure. Factors affecting blood pressure through stress include white coat hypertension, job strain, race, social environment, and emotional distress. Furthermore, when one risk factor is coupled with other stress producing factors, the effect on blood pressure is multiplied.

A variety of non-pharmacologic treatments to manage stress have been found effective in reducing blood pressure and development of hypertension, examples of which are meditation, acupressure, biofeedback and music therapy. This all the more important in our age where people put in 70 hour work in a week, attend endless committee meetings, and respond constantly to cell phones, stress has become a prevalent part of people’s lives; therefore the effect of stress on blood pressure is of increasing relevance and importance.

Summary

Hypertension management and the possibility of cure requires an integrated approach. Both the medical care-givers and patients need to understand the limitations and pitfalls of current practice, and must remain open to supportive treatment. The role of meditation, mindfulness, exercise, diet and overcoming stress has been accepted by modern medicine. Professional bodies like American Heart Association accept that limits defining hypertension is quite arbitrary. New recommendations for people above the age of 60 and who are non-diabetic persons and who do not suffering from chronic kidney disease set the goal of 150/90 mmHg as the goal.

Further reading

Elaine Lewis on Hypertension: The High Blood Pressure Snow Job

References   [ + ]

1. http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/causes/con-20019580
2. http://www.nhlbi.nih.gov/health/health-topics/topics/hbp/signs#
3. Herper M: America’s most popular drugs: a narcotic painkiller tops Forbes’ list of the most prescribed medicines. ForbesMay 11, 2010
4. Welch HG, Schwartz LM, & Woloshin S: Overdiagnosed: Making People Sick in the Pursuit of HealthBoston, MA: Beacon Press; 2011:171–172.
5. Yoon SS, Ostchega Y, & Louis T: Recent trends in the prevalence of high blood pressure and its treatment and control, 1999–2008. NCHS Data Brief. 2010;Oct(48):1–8.
6. Hunt LM, Kreiner M, & Howard Brody H: The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes, Annals of Family Medicine, September/October 2012 vol. 10 no. 5 452-460
7. Carretero OA, MD & Oparil S: Clinical Cardiology, Essential Hypertension, American Heart Association publication – Circulation.2000; 101: 329-335
8. Cooney D, Pascuzzi K: Polypharmacy in the elderly: focus on drug interactions and adherence in hypertension. Clin Geriatr Med. 2009 May;25(2):221-33. doi: 10.1016/j.cger.2009.01.005
9. Diao D, Wright JM, Cundiff DK, Gueyffier F: Intervention Review – Pharmacotherapy for mild hypertension,  The Cochrane Collaboration published in The Cochrane Library 2012, Issue 8
10. Journal of the American Medical Association: JAMA 2014;311(5):507-520. doi:10.1001/jama.2013.284427
11. Touyz RM, Campbell N, Logan A, Gledhill N, Petrella R, Padwal R: The 2004 Canadian recommendations for the management of hypertension: Part III–Lifestyle modifications to prevent and control hypertension, The Canadian Journal of Cardiology [2004, 20(1):55-59]
12. Wang YF , Yancy Jr WS, Yu D ,  Champagne C , Appel LJ and Lin PH: The relationship between dietary protein intake and blood pressure: results from the PREMIER study – Journal of Human Hypertension (2008) 22, 745–754
13. Stamler J, Liu K, Ruth KJ, Pryer J, Greenland P. Eight-year blood pressure change in middle-aged men: relationship to multiple nutrients.Hypertension 2002; 39: 1000–1006
14. Dickey RA, Janick JJ: Lifestyle Modifications In The Prevention And Treatment Of Hypertension, Endocrine Practice, Volume 7, Number 5/September/October 2001

A realistic time-frame for healing

Healing has been described as the “process” of becoming whole again. It is a personal experience of transcending suffering – an experience that is independent of illness, impairment, cure of disease or even death. Such a process can be immensely helped by bio-energy based, non-local, and supernatural pathways(1)Levin, Jeff & Mead, Laura: Bioenergy Healing: A Theoretical Model and Case Series, Explore,  May/June 2008, Vol. 4, No. 3 201 doi:10.1016/j.explore.2008.02.005. The marriage of science and medicine has empowered doctors and physicians to affect cures, to prevent illness, and to eradicate disease. But our doctors are trained as bio-medical scientists, so they naturally focus on diagnosis, treatment, and prevention of disease. In the pursuit of delivering cure, the concept of healing has been overlooked.

What is medical science’s take on healing?

Interestingly, modern medicine has no accepted definition of healing, hence it only concerns itself with the mechanics of the physiological processes related to curing(2)Egnew, Thomas R: The Meaning Of Healing: Transcending Suffering, Annals of Family Medicine,www.annfammed.org, vol.3, no.3, May/June 2005. However, a number of renowned doctors and scientists like Candace Pert, Deepak Chopra, Bernie Siegel, Bruce Lipton, Judith Orloff, Christiane Northrup, Herbert Benson, and others, are advocating, and endorsing the incorporation of Meditation, Yoga, Visualization and Guided Imagery in their professional practice to help people heal.

Physiology of wound healing

Physiology of wound healing

In recent times physicians like Michael Kearney and Balfour Mount(3)Mount B, Kearney M. Healing and palliative care: charting our way forward. Palliat Med 2003;17: 657–8are asking the medical community to “re-incorporate healing into the medical mandate”. Before we go further, let us try to understand what sets healing and curing apart?

Healing and Curing: don’t take them apart

When a person is in the “curing mode”, the goal is survival. Not just physical survival – but the survival of everything a person identifies with – and it includes physical appearance, lifestyle, relationships and all that makes up his/her life. In other words, the goal of curing is to avoid change.

On the other hand, healing comes from the acceptance of change. With this acceptance comes a new sense of oneself as a person (perhaps with disease), with a new experience of integrity and wholeness that is different than the old status quo.

In curing, the person depends on the expertise of the practitioner to control disease; in healing, the patient begins to realize that it is his or her own resources that will finally lead to growth and that he or she is responsible for managing those resources.

In the curing mode the basis of knowledge is scientific and is driven by evidence-based practice. In the healing mode this approach is not helpful. At the heart of healing is the relationship of one person to another. Art rather than science is required to keep curing and healing together.

In the curing mode, the physician, (through his knowledge and expertise concerning disease), clearly has more power. That is why the patient consulted him in the first place. In the healing mode the power shifts toward the patient. It is within the patient that healing will occur and it is the patient who will make the healing journey. The physician’s role is that of accompaniment.

The Wounded Healer

To do this effectively the physician needs to be able to put part of himself in the patient’s shoes and thus adopt the “wounded healer” role. In their desire to be detached and unbiased, the doctors often loses touch with the patient. Carl Jung learned that it was through his own suffering that he learnt more, than through the study of books or application of intellect. He saw the therapeutic process as mutual and dialectic with both participants equally involved and affected, or as he put it – both are “in treatment.” Jung insisted “You (the therapist/caregiver) can exert no influence if you are not susceptible to influence”(4)Jung, Carl: Collected Works, Vol. 16, page 71, Pantheon Books, 1977.

 The dynamics of the interaction would be different with every physician-patient pair, a complete contrast to the standardized requirements of science.

Homeopathic perspective

The founder of Homeopathy, Dr. Samuel Hahnemann (1755-1843) was a great healer who brought about many “miraculous” cures, and the secret of his success lay in his practice of combining the art of healing with the mechanics of curing. Homeopathic practice is based on accepting that every practitioner-patient dialog is unique. Apart from objective signs and diagnostic tests, it is also the subjective symptoms of the patient that describe the disease in its totality with the central focus on the person and not on the model description of a disease.

In order that clinical medicine does not remain just a search for disease, the practice and teaching of medicine must emphasize the fundamental premise that healing is the doctor’s primary obligation. Hence medical curriculum must include explicit training in a specific clinical method, whose cardinal features include observation, attentive listening and clinical reasoning(5)Boudreau JD, Cassell EJ, Fuks A:Medical Education 2007 Dec;41(12):1193-201. Epub 2007 Nov 2.. This has been at the core of Hahnemannian philosophy.

References   [ + ]

1. Levin, Jeff & Mead, Laura: Bioenergy Healing: A Theoretical Model and Case Series, Explore,  May/June 2008, Vol. 4, No. 3 201 doi:10.1016/j.explore.2008.02.005
2. Egnew, Thomas R: The Meaning Of Healing: Transcending Suffering, Annals of Family Medicine,www.annfammed.org, vol.3, no.3, May/June 2005
3. Mount B, Kearney M. Healing and palliative care: charting our way forward. Palliat Med 2003;17: 657–8
4. Jung, Carl: Collected Works, Vol. 16, page 71, Pantheon Books, 1977
5. Boudreau JD, Cassell EJ, Fuks A:Medical Education 2007 Dec;41(12):1193-201. Epub 2007 Nov 2.

Randomized Controlled Trials: The Golden Calf?

Practitioners of the Homeopathic Art of Healing are cautioned to stay clear from hypotheses concerning life sciences.(1)Hahnemann S: Footnote to the 1st Aphorism – Organon of Medical Art, 6e, Ed. O’Reilly WB, Birdcage, 1996 Indeed, our understanding of life, health and disease have evolved from a simple homeostatic model, to a resilient system and now we are moving towards a more comprehensive complex-adaptive model. This means that as Healers, we must accept and respect the cyclic nature of growth, adaption, transformation, and, in the end, collapse.(2)Holling, C. S. 2004. From complex regions to complex worlds. Ecology and Society 9(1): 11. Disease is not an external entity that is to be destroyed. It is an expression of the innovation and adaptation of the Life Force of an individual in distress.

Complexity and Life Systems

Complexity in any system results from the inter-relationship, inter-action and inter-connectedness of elements within a system and between a system and its environment. Only in recent times are we learning about the interactions and inter-relationships between ecology, weather, cultural attitudes, immunology, evolution and a whole slew of other factors. The complex-adaptive system is characterized by a state of paradox – a dance of stability and instability, a play between competition and cooperation, and coexistence of order and disorder. In other words, we must move away from the comfort zone of inadequate and simplistic cause-and-effect theorems.

From Art to Science

The practice of healing has undergone a sea change over the centuries. Once considered an Art, it is now firmly in the domain of Science. Indeed, in the past two centuries or so, science has expanded our knowledge of the body and pathological conditions that occur in disease. However, in practice, the person-in-disease does not respond to treatment the way the physicians want or expect.

Now consider this. On the one hand we have a silent killer, known as iatrogenesis, or death-by-medicine,(3)Null Gary PhD, Dean C MD, et al: Death by Medicine, Life Extension Magazine March 2004 which is the third leading cause of death in treatment of disease. On the other hand we have an even more embarrassing situation: oftentimes patients will respond to a placebo, a non-medicinal sugar pill, which should logically produce no physiological effects at all! Thus, a truly rational therapeutic model still eludes us. Simply put, we have to accept that medicines can kill while placebos can cure.

Randomized Controlled Trial: The Golden Calf or A Gold Standard?

To overcome this dichotomous situation, researchers have evolved a system of evaluating a treatment, medicinal, surgical or otherwise, known as the Double-Blind Randomized Controlled Trial (RCT).

Briefly, the RCT procedure is conducted as follows:

  1. A number of similar people are randomly assigned to two (or more) groups to test a specific drug or treatment
  2. One group (the experimental group) receives the treatment being tested
  3. The other (the comparison or control group) receives an alternative treatment, a dummy treatment (placebo) or no treatment at all
  4. The groups are followed-up to see how effective the experimental treatment was
  5. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically
  6. The trial is deemed double-blind because neither the participants nor the evaluators know who is getting the treatment and who is being given the placebo

RCTs are claimed to be “true experiments” conducted with scientific rigor, and are considered to be the gold standard and demonstrate a cause-and-effect relationship between an intervention and an outcome. RCT are the bedrock on which present day clinical practice of Evidence Based Medicine (EBM) is supposed to rest. However, it is being increasinly accepted that there are some fundamental shortcomings in the assumptions on whic RCTs are based.(4)Ventegodt S, Andersen NJ, et al: Evidence-Based Medicine: Four Fundamental Problems with the Randomized Clinical Trial (RCT) used to document chemical medicine. International Journal of  Adolescent Medicine & Health. 2009 Oct-Dec;21(4):485-96

How does it work out in the clinic?

Lancet, the world’s leading peer-reviewed medical journal admits that RCTs most often lack evidence that the treatment under investigation will prove of any use to a real patient seen by a doctor in the clinic.(5) Rothwell PM: External validity of randomized controlled trials: “To whom do the results of this trial apply?”. Lancet 2005; 365: 82–93 Indeed, RCTs have been criticized a lot in recent times. It seems a community of researchers have fallen prey to  a ritualistic worship of the metaphorical Golden Calf of RCT. Loes Knappen of McGill University, Canada states that we have reached a stage where, “The legitimacy of EBM relies neither on experts nor numbers, but on distinct procedures for handling (non) Evidence, reflecting its ‘regulatory objectivity’”.(6)Knappen L: Being evidence based in the absence of evidence: The management of non-evidence in guideline development. Social Studies of Science October 2013, vol. 43 no. 5 pp. 681-706

In the latest edition of a standard textbook on RCTs, authors Jadad and Enkin admonish us “to stop worshiping the randomized controlled trial as if it were a talisman that would guarantee objectivity”.(7) Jadad AR & Enkin MW: Randomized Controlled Trials: Questions, Answers and Musings, second edition, BMJ Books/Blackwell Publishing; 2007 The authors point out that RCTs do a good job to solve simple or even complicated problems, but have very limited use in complex problems. They advocate a multi-disciplinary approach. To cite an example, raising a child and treating dementia would hardly lend itself to RCTs.

In the course of his research, another respected researcher, Austin Bradford Hill, who authored Principles of Medical Statistics, lamented that the influence of statistical method (read RCT) on clinical practice has reduced research from one of assured certainty to one merely of modest advantage. He said, “At its best the RCT shows what can be accomplished with a medicine under careful observation and certain restricted conditions. The same results will not invariably or necessarily be observed when the medicine passes into general use”.(8)Quoted by Horton R: Common sense and figures: the rhetoric of validity in medicine – Bradford Hill Memorial Lecture 1999. Statistics in Medicine, 2000 Dec 15;19(23):3149-64.

So what do RCT do?

To be fair, RCTs do answer small questions that are only part of the complex-adaptive puzzle. Qualitative data pertaining to feelings of well-being, impact of a treatment on social life, using many interventions together to affect rapid healing, are but a few examples that point to the shortcomings of RCTs. RCTs in their present avatar are data driven, so subjective feelings have little influence in measuring outcomes.

Another area of research that is often ignored are “Single-Case Experiments”.  This is another important source of evidence that is most often overlooked.(9) Kazdin, A.E : Single-Case Research Designs: Methods for Clinical and Applied Settings, 2nd edition. New York: Oxford University Press, 2010 In contrast to RCTs, which involve many subjects and few observations, single-case designs involve many observations but often few subjects.

Is Homeopathy any different?

Every practicing homeopath has had to bear the insults of the worshipers of the Golden Calf who state that Homeopathy does poorly in RCTs and that its remedies are no more than placebos. However, Homeopathy fairs no better or worse in RCTs than conventional medicine. By the end of 2010 RCTs of homeopathy 41% had a balance of positive evidence, 7% had a balance of negative evidence, and for 52% no conclusions could be drawn either way(10)http://twinhealers.in/homeopathy. RCTs of conventional medicine, indicate that 44% of the reviews concluded the interventions studied were likely to be beneficial (positive), 7% concluded that the interventions were likely to be harmful (negative), and 49% reported that the evidence was non-conclusive(11)El Dib RP, Atallah AN, Andriolo RB: Mapping the Cochrane evidence for decision making in health care. Journal of Evaluation in Clinical Practice 2007;13:689–692.

Sadly, it is not realized that in the past two decades Homeopathy has consistently met the standards of RCT protocols, even in healing conditions that are considered “incurable” by modern medicine. And it does so without increasing virus and bacterial resistance while also improving immunity, mental and psychological well-being, raising happiness and most of all, doing no harm. At the same time homeopaths are open and inclusive as they realize that health and sickness are a part of a complex-adaptive system and only an integrative approach will help to heal.

Most critics of Homeopathy fail to realize that our Materia Medica  has been collated over more than two centuries after each remedy has been tested for producing symptoms in persons-in-health and have been confirmed in the clinic to heal persons-in-disease.

Dr. Bernard Lown, renowned cardiologist and healer echoes the sentiment of Hahnemann when he states that, “The real crisis in medicine today is not about economics, insurance, or managed care—it’s about the loss of the fundamental human relationship between doctor and patient. The art of healing does not mean abandoning the spectacular advances of modern science, but rather incorporating them into a sensitive, humane, enlightened approach to medical care”.(12)Lown, Bernard MD: The Lost Art of Healing, Balantine Books, 1996

References   [ + ]

1. Hahnemann S: Footnote to the 1st Aphorism – Organon of Medical Art, 6e, Ed. O’Reilly WB, Birdcage, 1996
2. Holling, C. S. 2004. From complex regions to complex worlds. Ecology and Society 9(1): 11.
3. Null Gary PhD, Dean C MD, et al: Death by Medicine, Life Extension Magazine March 2004
4. Ventegodt S, Andersen NJ, et al: Evidence-Based Medicine: Four Fundamental Problems with the Randomized Clinical Trial (RCT) used to document chemical medicine. International Journal of  Adolescent Medicine & Health. 2009 Oct-Dec;21(4):485-96
5. Rothwell PM: External validity of randomized controlled trials: “To whom do the results of this trial apply?”. Lancet 2005; 365: 82–93
6. Knappen L: Being evidence based in the absence of evidence: The management of non-evidence in guideline development. Social Studies of Science October 2013, vol. 43 no. 5 pp. 681-706
7. Jadad AR & Enkin MW: Randomized Controlled Trials: Questions, Answers and Musings, second edition, BMJ Books/Blackwell Publishing; 2007
8. Quoted by Horton R: Common sense and figures: the rhetoric of validity in medicine – Bradford Hill Memorial Lecture 1999. Statistics in Medicine, 2000 Dec 15;19(23):3149-64.
9. Kazdin, A.E : Single-Case Research Designs: Methods for Clinical and Applied Settings, 2nd edition. New York: Oxford University Press, 2010
10. http://twinhealers.in/homeopathy
11. El Dib RP, Atallah AN, Andriolo RB: Mapping the Cochrane evidence for decision making in health care. Journal of Evaluation in Clinical Practice 2007;13:689–692
12. Lown, Bernard MD: The Lost Art of Healing, Balantine Books, 1996

Not by medicine alone

In her book Mind Over Medicine: Scientific Proof That You Can Heal Yourself, Dr Lissa Rankin lays out many remarkable examples of how the mind can affect the body. But first let us take a look at some other facts.

Samuel Hahnemann (1755-1843), the Founder of Homeopathy, had exhorted that a true Practitioner of the Healing Art must be a preserver of health and know the things that derange health and cause disease.(1)Hahnemann, S: The Organon of Medical Art, 6e, English translation, Birdcage Press 1996 In the past 150 years, the efforts of modern medicine have focused primarily on finding the infection causing organism (which is thought to cause the disease) and developing medicines to effectively kill the same. Modern pharmacology has fine tuned the delivery of medicines by working on receptor interactions at the cell wall and interactions with enzymes.

Disease, alas is not just the effect of micro-organisms!  There are many other (important) factors to be taken into account. For example, going by the definition of epidemic, as defined by the US Centers for Disease Control and Prevention, an attack rate of 15 cases of meningococcal disease per 100,000 people for two consecutive weeks constitutes an epidemic. What explains the fact that the remaining 99,985 people in the population of 100,000 remain uninfected?(2)http://www.slate.com/articles/news_and_politics/explainer/2003/12/outbreaks_vs_epidemics.html Surely there is more than meets the eye?

Epidemiology, or the studies of the patterns, causes, and effects of health and disease conditions, began as early as the 17th century. At that time, this study was centered on the ill effects of poverty, poor housing and work environments.(3)Berkman, LF & Kawach, I: A Historical Framework for Social Epidemiology, Oxford University Press, 2000 However, the domination of pharmaceutical conglomerates and other vested interests have shifted the focus of research from public hygiene, psychosocial effects, and psychosomatic causes, to biochemistry. Pharmaceutical companies are now actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers. Some programs of these corporations are now better described as disease mongering: i.e., widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments. One form of doing this is by ostensibly engaging in raising public awareness about under-diagnosed and under-treated problems, and promoting a view that the condition is widespread, serious, and treatable.(4)Moynihan, R: Selling sickness: the pharmaceutical industry and disease mongering, BMJ 2002;324:886

So let us take a view of medical history. The infections that ravaged at the beginning of the industrial revolution were tuberculosis, cholera and typhoid. Tuberculosis, reached a peak over two generations. In New York in 1812, the death rate was estimated to be higher than 700 per 100,000. By 1882, when Koch (he was later awarded the Nobel Prize in 1905) first isolated and cultured the bacillus, it had already declined to 370 per 100,000. The rate was down to 180 when the first sanatorium was opened in 1910, and before antibiotics became routine (1940), it had slipped into eleventh place with a rate of 48.(5)Illich, Ivan: Medical Nemesis-The Expropriation of Heath, Random House 1976 Strangely, despite all the advances in medicine, the rate of disease in London in the year 2011 again rose to 44.9 cases per 100,000.(6)Pealing, L et al: The resurgence of tuberculosis and the implications for primary care, British Journal of General Practice, Jul 2013; 63(612): 344–345

Cholera, dysentery, and typhoid similarly peaked and dwindled outside the physician’s control. By the time their etiology was understood and their therapy had become specific, these diseases had lost much of their virulence and hence their social importance. The combined death rate from scarlet fever, diphtheria, whooping cough, and measles among children up to fifteen had declined nearly 90% between 1860 and 1965, long before the introduction of antibiotics and widespread immunization.

So what was the reason for this spectacular improvement?

In part this may be attributed to improved housing and to a decrease in the virulence of micro-organisms, but by far the most important factor was a higher host-resistance due to better nutrition. In poor countries today, diarrhea and upper-respiratory-tract infections occur more frequently, last longer, and lead to higher mortality where nutrition is poor, no matter how much or how little medical care is available.(7)Scrimshaw,CE et al: Interactions of Nutrition and Infection, Geneva, WHO, 1968 In England, by the middle of the nineteenth century, infectious epidemics had been replaced by major malnutrition syndromes, such as rickets and pellagra.

The times that followed were dominated by the diseases of early childhood and, somewhat later, by an increase in duodenal ulcers in young men. When these declined, the modern epidemics took over: coronary heart disease, emphysema, bronchitis, obesity, hypertension, cancer (especially of the lungs), arthritis, diabetes, and so-called mental disorders. Despite intensive research, we have no complete explanation for the genesis of these changes. Pollutants, toxicants, food additives or pesticides were often blamed for this. John Cassel, Professor of Epidemiology at the University of North Carolina proposed the hypothesis of “stress buffering”, which states that susceptibility to disease or slow recovery from illness is affected strongly by social environment.(8)Cassel, J: The contribution of social environment to host resistance, 1976 American Journal of Epidemiology, 104, 107-123

From the above, scholars tend to believe that medicines alone cannot be credited with the elimination of old forms of mortality, and nor should it be blamed for the increased expectancy of life spent in suffering from the new diseases. For more than a century, analysis of disease trends has shown that the environment is the primary determinant of the state of general health of any population.

That is why, a Healer who is well versed with practices like Meditation, Yoga, Creative Visualisation, supplemented by advice on Homeopathy and Bach Flower Remedies can guide you to Heal Thyself.

References   [ + ]

1. Hahnemann, S: The Organon of Medical Art, 6e, English translation, Birdcage Press 1996
2. http://www.slate.com/articles/news_and_politics/explainer/2003/12/outbreaks_vs_epidemics.html
3. Berkman, LF & Kawach, I: A Historical Framework for Social Epidemiology, Oxford University Press, 2000
4. Moynihan, R: Selling sickness: the pharmaceutical industry and disease mongering, BMJ 2002;324:886
5. Illich, Ivan: Medical Nemesis-The Expropriation of Heath, Random House 1976
6. Pealing, L et al: The resurgence of tuberculosis and the implications for primary care, British Journal of General Practice, Jul 2013; 63(612): 344–345
7. Scrimshaw,CE et al: Interactions of Nutrition and Infection, Geneva, WHO, 1968
8. Cassel, J: The contribution of social environment to host resistance, 1976 American Journal of Epidemiology, 104, 107-123

Screening – Does it Lead to Overdiagnosis?

Screening, in medicine, is a strategy used to identify an unrecognized disease in individuals often without signs or symptoms. This can include individuals with pre-symptomatic or unrecognized symptomatic disease. As such, screening tests are somewhat unique in that they are performed on persons apparently in good health. Screening interventions, we are told, are designed to identify disease early, thus enabling earlier intervention and management in the hope to reduce mortality and suffering from a disease.

Given below are some findings published in the British Medical Journal, an international peer reviewed medical journal, which has been published without interruption since 1840.

We are told that regular mammography screening is done to reduce mortality from breast cancer. It was argued that screening would either lead to less invasive surgery or simpler treatment. In reality it is found that it actually results in 30% more surgery, 20% more mastectomies, and more use of radiotherapy because of overdiagnosis (1)Gøtzsche PC, et al. Breast screening: the facts-or maybe not: BMJ 2009;338:b86.  Dr. Susan Bewley, Professor of complex obstetrics at King’s College London, states that for every 15 women who are given a diagnosis through screening and who will undergo treatment, only one life will be saved and three women will have been treated unnecessarily (2)Kmietowicz, Zosia. New breast screening leaflet still denies women the full picture, says critic: BMJ 2013;347:f5735.

Recent studies point to the fact that screening, typically for breast cancer, has often led to overdiagnosis. A 25 year study in Canada shows that annual mammography does not result in a reduction in breast cancer specific mortality for women aged 40-59 beyond that of physical examination alone or usual care in the community (3)Miller AB, et. Al.Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial: BMJ 2014;348:g366. As a matter of fact, a row has erupted in Switzerland after the Swiss Medical Board recommended that the country’s mammography screening programme for breast cancer be suspended because it leads to too many unnecessary interventions. In a report made public on 2 February 2014, the Board said that while systematic mammography screening for breast cancer saved 1-2 women’s lives for every 1000 screened, it led to unnecessary investigations and treatment for around 100 women in every 1000. “The desirable effect is offset by the undesirable effects,” said the report.(4)Arie S, Switzerland debates dismantling its breast cancer screening programme: BMJ 2014;348:g1625

A report from another quarter also makes interesting reading. Many elderly men in the US are being screened inappropriately for prostate cancer, say researchers. The very old and those in poor health are unlikely to live long enough to enjoy any potential benefits from screening, whereas the harms are immediate and include anxiety, false positive tests (5)Inappropriate prostate cancer screening is common among elderly US men: BMJ 2006;333:1112. A national prostate cancer awareness programme in New Zealand has been criticised for glossing over the harms of prostate specific antigen (PSA) testing and of promoting population screening by the “back door.” The $US3.5million scheme is intended to provide men with access to evidence based, high quality information to help them decide whether they need their prostate checked. Posters and patient information booklets were sent to every general practice in the country last month. But the resources have prompted an angry reaction, including calls for doctors to boycott the programme outright (6)Brill D. New Zealand prostate cancer awareness programme is likely to increase unnecessary PSA testing:  BMJ 2013;347:f7537.

Does screening for depression improve outcomes in primary care? The UK National Screening Committee has determined that there is no evidence of benefit from depression screening to justify costs and potential harms and has recommended against it (7)Thombs BD. Does depression screening improve depression outcomes in primary care?BMJ 2014;348:g1253.

Here is another finding. Bowel cancer screening with fecal occult blood testing was thought to reduces the risk of dying from bowel cancer, however a new long term study has shown that bowel cancer screening does not influence all cause mortality, so patients won’t necessarily live longer (8)Jacqui W. BMJ 2013;347:f5773.

I leave it to the reader to draw the appropriate conclusions.

References   [ + ]

1. Gøtzsche PC, et al. Breast screening: the facts-or maybe not: BMJ 2009;338:b86
2. Kmietowicz, Zosia. New breast screening leaflet still denies women the full picture, says critic: BMJ 2013;347:f5735
3. Miller AB, et. Al.Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial: BMJ 2014;348:g366
4. Arie S, Switzerland debates dismantling its breast cancer screening programme: BMJ 2014;348:g1625
5. Inappropriate prostate cancer screening is common among elderly US men: BMJ 2006;333:1112
6. Brill D. New Zealand prostate cancer awareness programme is likely to increase unnecessary PSA testing:  BMJ 2013;347:f7537
7. Thombs BD. Does depression screening improve depression outcomes in primary care?BMJ 2014;348:g1253
8. Jacqui W. BMJ 2013;347:f5773