4 On profiling and diagnosis
Appreciating the patient’s predicament
The following chapters will explore the three basic, or classical, strategies used to assess the patient: case history-taking; physical examination and investigations. We will consider their relevance and application in phytotherapy. Before moving on to these, however, it will be useful to consider the general issues and challenges posed by, as well as the opportunities that may arise from, the process of attempting to understand patients and their predicaments and to assess and diagnose their conditions.
Foucault (1963) writes of: ‘the endless task of understanding the individual’. The consultation provides a bounded space to pursue this quest – the attainment of which must always be limited but also, crucially, must always attempt to be sufficient. Before setting out on this journey of discovery, the practitioner needs to be equipped with a sense of the extent to which any person is knowable and any condition is diagnosable. It is a cliché beloved by many who speak about holistic medicine that the goal is to ‘treat the whole person’, the correlate association being that it is possible to first know the whole person; an assertion that stands in need of challenge. A further well-worn maxim is that the aim of holists is to treat the ‘cause of disease, not its symptoms’, again implying that causes can be commonly discovered. These blandishments are part of the hubris of some CAM proponents and practitioners and one looks askance at those who have actually spent much time with patients who continue to proffer them as attainable absolutes. Indeed, the uncritical reiteration of such statements proffered as mantras of holism has served to denigrate the notion of holism itself.
• In pursuit of the above goal the practitioner should temper her approach in the light of, and with respect for, the patients’ agenda and the degree to which the patient either desires or is able to participate.
If the practitioner is to be successful in helping a wide range of patients – the goal of the phytotherapist as a generalist – she must be sensitive to the hopes, wishes, preferences and desires of individual patients and flexible and creative in adapting her approach in response. A base for proceeding in this way lies in the appreciation and exploration of the fact that both patients and practitioners bring their own expectations and agendas to the consultation. Much benefit will accrue if the practitioner seeks to perceive the patient’s expectations and agenda and to critically reflect on her own.
Practitioners may assume that they know what patients in general want from the clinical encounter but this, in actuality, varies between patients. Collins et al. (2007) observe that: ‘there continue to be limits to, and uniqueness in, individuals’ experiences of healthcare, for while some patients expect greater understanding and involvement, others want little’.
Not every patient is unhappy when their symptoms are superficially relieved (!) and not every patient has the orientation, temperament, will or capacity to engage in an in-depth exploration of their being. The phytotherapist may be disappointed when the patient shows no interest in, or even clearly voices their opposition to, partaking in a voyage to the outer and inner reaches of their existence. Patients are not always up for a profound experience, they may say things like: ‘Look, I’m sorry, but have you just got something to stop this itching?’
Peck et al. (2004) distinguish between patient expectations and patient requests: ‘An expectation refers to what a patient wants to happen or thinks will happen, while a request refers to what a patient asks of the clinician’. Expectations commonly remain unvoiced and therefore unknown unless the practitioner directly asks the patient to talk about them. Peck considers that: ‘relatively little is known about the specific expectations patients bring to the clinical encounter’ [original italics] but that: ‘Patients’ expectations are varied and often vague. Clinicians trying to implement the values of patient-centred care must be prepared to elicit, identify and address many expectations’.
Barry et al. (2000) studied unvoiced agendas in general practice consultations and their findings and conclusions warrant extended discussion here. While noting the difficulty in defining the notions of expectations and agendas, they consider patient agendas to include, yet constitute more than patient expectations so that patient agendas involve ‘ideas, concerns and expectations’. One might additionally suggest that patient agendas include, or are moulded by, the patient’s values, preferences, goals, aspirations, biases and personal influences (e.g. family opinions, pressures and commitments). Patients’ agendas may be divided into particular areas of concern such as social agendas and emotional agendas. These can be combined into a concept of ‘total agendas’. The extent to which practitioners are able to determine patient agendas is based on their beliefs and behaviours:
What doctors both believe and do influences the expression of patients’ agendas. Doctors may overestimate the extent to which patients are primarily concerned with medical treatment rather than with gaining information and support. Unless patients are overtly distressed doctors may have trouble in recognising those who are seeking support.
The agenda items that were most commonly voiced in this study had to do with presentation of symptoms and making requests for diagnosis and treatment – the ordinary business of the consultation seen from a stereotyped view. The agenda items left unvoiced included:
These themes have to do with subtleties and complexities that may not be considered by the patient to be allowable in the consultation format, and issues which, if voiced, might be the source of challenge to the practitioner and possibly lead to conflict. The authors ponder whether: ‘Maybe patients are behaving as they believe they are expected to rather than as they would like’. The study also contrasted the agendas patients revealed to the researchers with those revealed to practitioners, concluding that:
In consultations patients seem only partially present, with only limited autonomy – that is, to make requests but not to suggest solutions. Outside consultations patients are more fully present: as socially and contextually situated, thinking, feeling, people, with their own ideas on their medical condition and opinions and possible criticisms of medical treatments.
Phytotherapists may contest that patients in herbal medicine consultations are empowered to be more themselves and therefore more forthcoming. Certainly the extended and in-depth nature of the phytotherapy consultation, coupled with the possibility that patients may feel less inhibited (and intimidated) when seeing a non-conventional practitioner, may be beneficial in facilitating greater expression on the part of patients. Yet phytotherapy practitioners still impose their own beliefs on the consultation and patients may similarly be wary of entering into areas of challenge and potential conflict regarding the practice of phytotherapy itself.
Overcoming obstructions that prevent the free and full expression of the patient’s agenda is vitally important since: ‘Patients have many needs and when these are not voiced they can not be addressed … This suggests that when patients and their needs are more fully articulated in the consultation better healthcare may be effected’.
A more complete view of the patient’s agenda was only possible through a methodology that asked patients to present their full selves. When research methods are structured closer to the lifeworld – qualitative, loosely structured, open ended, people centred – a fuller more complex situated view of people and their agenda is gained.
The practitioner needs first to be aware of the potential scope of the patient’s agenda and the range of specific items it may contain. They then need to be open to receiving and attending to this broad array of factors and prepared to deal with the implications of doing so. A major implication for conventional practitioners will be the need for more time in the consultation – this is not an issue for most phytotherapists. A fundamental implication for all practitioners however, is exposure of the practitioner herself to risk, particularly the risk of hearing things that are personally difficult and challenging and which may cause one to question deeply and dearly held beliefs about the nature of practice. The practitioner may therefore feel resistance to engaging with the patient’s full agenda. One example of risk in phytotherapy would be to invite the patient to express their full agenda regarding the herbal prescription itself. Although this may initially sound straightforward, it can actually strike at the heart of the phytotherapist’s core beliefs and self-image as a practitioner – for if the patient is ambivalent or negative about the prescription where does that leave the practitioner?
Some of these questions provide the patient with an opportunity to say that the medicine does not appear to be helping or may be causing detrimental effects or is not actually being taken! Findings of this type are not what the practitioner ideally wants to hear and therefore may not usually be open to hearing. Working in this way does not mean that the patient’s perception should be uncritically accepted or go unchallenged – it simply gives a clearer picture of what the patient is actually thinking and feeling. It is very common, for example, when asking patients the type of questions above to have an exchange along the following lines:
Phytotherapist: ‘Well I think, um, you know herbs can work quite subtly, and, er, for instance do you remember that when I first saw you, you were having headaches twice a week and you’ve just told me that you haven’t had any headaches for the last 6 weeks? And I have been trying to treat that with the herbs’.
Of course this is only one possible scenario, others may lead the practitioner to question how effective she is being as a phytotherapist. Such questions, squarely faced, generally lead not to abandonment of the modality but to increased appreciation of how to effectively apply it. Nonetheless, practitioners seem to intuit that there is danger in asking patients to express themselves in areas relating to the practitioner’s core beliefs and practices, and they may shy away from encouraging this, lest the power of these is diminished as a consequence. There is an important correlate here, however, which, when appreciated, may encourage the practitioner to be bold in exposing herself to the risk of personal challenge. It is this – that the more open the practitioner is in hearing the patient’s total agenda, the more powerful she becomes as a catalyst to the patient’s self-discovery and self-healing. If the opening-up of the consultation to the full breadth of the patient’s thoughts, ideas and expectations diminishes the place or power of the ‘remedy’, it will be compensated by an increase in the potency of the practitioner as a remedy in and of herself.
In exploring the patient’s expectations and agenda, the practitioner must inevitably arrive at a point of critical reflection on her own expectations and agenda – regarding the patient, the consultation and her modality. A crucial development is for the practitioner to cease to identify her healing identity primarily with her tools (e.g. herbs) but rather with her self, in tune with Gordon’s (1982) definition of holistic medicine as: ‘an attitudinal approach to healthcare rather than a particular set of techniques’.
To bring things together: practitioner and patient both approach the consultation with their own expectations of what might, or should, come of it and with their own agenda around this. Each may make assumptions about the expectations and agenda of the other and in doing so, each is likely to reach some conclusions that are erroneous. Additionally, each will be ignorant of many of the specific expectations and agenda items the other holds. Matters are compounded by the fact that many expectations are poorly formed, vague or existing on the peripheries of consciousness – for both patient and practitioner. While we have discussed the usefulness of practitioners questioning patients regarding their expectations/agenda for the consultation, the patient would also be justified in asking the practitioner the same thing.
The patient’s agenda reflects her ideas and questions about her illness, her hopes and expectations of the doctor, her feelings, her fears and her problems of living. The doctor’s agenda is concerned with correct diagnosis of the patient’s complaints. It is the doctor’s responsibility to respect the patient’s agenda and to reconcile this with his own.
This represents a questionably narrow, passive and acquiescent view of the practitioner. A different take on considering the practitioner’s agenda would be to consider what the practitioner personally hopes to get out of the consultation process since agendas are based on goals. Daghio et al. (2003) and Fairhurst and May (2006) have looked at the elements that general practitioners felt as satisfying in their work. Daghio et al. found that:
Doctors’ reports of satisfying and unsatisfying experiences during consultations were primarily concerned with developing and maintaining relationships rather than with technical aspects of diagnosis and treatment.
It seems likely that this statement would hold true for practitioners in other fields and modalities, certainly it would seem to apply to phytotherapists. Fairhurst and May further discovered that personal aspects pertaining to the doctor were most highly associated with feelings of satisfaction:
… greatest satisfaction seemed to derive from consultations in which doctors perceived they personally had contributed to a successful outcome by deploying personal attributes in addition to formal medical knowledge and technical skills.
The consultation experience appeared to open the doctors’ identity to scrutiny and potential maintenance, challenge or modification. Mostly the consultation experience allowed doctors to maintain a coherent sense of themselves as doctors, and generally these consultations were satisfying.
So it appears that part of a practitioner’s agenda in the consultation is to facilitate and experience satisfying relationships and to conduct work on the self as well as on the patient. We might restate and posit this last remark as representing the practitioner’s two agendas in the consultation: work on the patient and work on the self. The two agendas are likely to have synergistic positive effects if both are attended to and, conversely, each is likely to suffer if the other one is neglected. Returning to Barry et al.’s findings we might suggest that the patient can only be fully present in the consultation if the practitioner is also fully present. Being ‘fully present’ entails being fully alive to and engaged with the totality of the patient’s predicament and agenda while dynamically applying one’s whole self to the moment in a spirit of openness and mutual discovery. At this point let us attempt to summarize some of the implications of the foregoing discussion for the consultation in more detail.
At the outset of the consultation, and/or at other relevant points, it is crucial to ask patients about their expectations and explore the full extent of their total agenda. Some aspects of these (i.e. expectations/agendas) may not be accessible to patients early in the consultation but may emerge as an outcome of the consultation process or between or during subsequent consultations. Since expectations/agendas evolve, it is important to return to check this ground repeatedly over time. Expectations/agendas should always be respected but not passively accepted. If the patient’s expectations are vague, then some exploration to achieve greater clarity is required. If the patient’s expectations appear to the practitioner to be unreasonable, inappropriate or unachievable, they will need to be queried or challenged. The practitioner may take the role of teacher in order to transform a patient expectation that she considers to stand in need of revision or modification.
My experience has been that the response to this type of question is typically both appropriate and realistic. Patients rarely expect or ask for the earth and it may often be possible for the practitioner to exceed the patient’s wishes. If such a question is left unposed, however, the practitioner may burden themselves with the assumption that the patient is looking for much greater results than is actually the case and the patient may be left uncertain as to whether the practitioner understood what they wanted.
Practitioners may be wary of asking many of the questions given in this section for fear of ‘opening up the floodgates’. There is a fear of being ‘swamped’ or overwhelmed by a ‘deluge’ of comment or information. Yet it is the job of the practitioner to ‘immerse’ themselves in the patients’ world.
From Barry et al. (2000) above, we have some hints as to how we might adapt the consultation structure, techniques and style to enable the patient to be more fully present in the consultation. Elements include:
The more tightly constrained the consultation is (including time constraints and rigid questioning routines) and the more practitioner-directed it is, the less chance there will be of allowing the patient to be fully present in the consultation. For many patients it will be helpful for the consultation to possess a certain fuzziness as regards structure and explicit aims, since this will help the patient feel liberated in expressing themselves – indeed, so that they may behave as they would like to rather than as they are expected to.
There is not only room for, but also a clear and urgent need for, innovation in consultation methodology and patient profiling in order to greater appreciate patient expectations and total agendas. Middleton et al. (2006) has demonstrated two methods that have yielded encouraging results: practitioner education and the use of agenda forms for patients to complete themselves. Their study found that:
If patients are encouraged to make their agenda explicit in consultations, doctors identify more problems although consultations last longer. Patients who completed an agenda form were more satisfied with the depth of the doctor–patient relationship. Similar changes were observed in the number of problems identified and the duration of consultations if doctors were taught to explicitly deal with the patients’ agenda.
As previously observed, the issue of time is not currently problematic for most phytotherapists in the UK. The phytotherapist is ideally placed to engage profoundly with the patient’s expectations and agenda, yet it is unclear (since there are few studies) whether this potential is being realized (though see Little for an interesting introduction to this area). Individual practitioners can raise their own awareness of this issue through directed reading and critical reflection and herbal medicine students should be trained to elicit patient expectations/agendas as a core element of practice.
Katz (1986) underlines the centrality of reflection in enabling patient autonomy:
… the right to self-determination about ultimate choices cannot be properly exercised without first attending to the processes of self-reflection and reflection with others. This holds true for patients as well as physicians.
I am not suggesting, however, that the conversations between physicians and patients be converted into an exploration of the psychological roots of patients’ and physicians’ motivations and expectations. This is neither warranted nor possible. I have in mind only a bona fide attempt by physicians and patients to explain what they wish from one another and what they can do for and with one another, and to clarify, to the extent possible, any misconceptions they may have of each others’ wishes and expectations. In the end, irreconcilable differences may persist. If they then realize that they must part company, at least they will do so with a greater appreciation of their respective position.
Although the strategies of case history-taking, physical examination and investigation are usually presented as three discrete yet complementary methods for exploring the patient’s condition, which can be deployed in an orderly manner to inform each other, the reality in practice is that they tend to have a messy and tense relationship that is frequently dysfunctional. Their professed relationship is that of a tripartite approach to diagnosis, yet definitive diagnosis is commonly unattainable in practice. The classic sequential procession from case history (generating hypotheses) to physical examination (clarifying the differential diagnosis) to investigation (confirming diagnosis) is rarely a straightforward one and often does not occur in this order, e.g. an abnormality found on routine screening physical examination or investigation may lead to a case history being taken.
In phytotherapy, as in other medical modalities, the case history is by far the most generally important of the three strategies. The vast majority of the consultation time is spent on the consultation with most phytotherapists, like most doctors, paying scant regard to physical examination. Not that physical examination is without merit, just that it tends in practice to be given a minor role and is frequently overlooked. Investigations take place outside of the consultation so cannot properly be regarded as part of the consultation, although they provide information that may, indeed, inform it.
Although phytotherapists can refer patients to private laboratories and specialist clinics for investigations to be undertaken, this rarely occurs. It is generally more convenient and economic to advise the patient to visit their GP and request the relevant test/s or to contact the GP on the patients’ behalf. In either case, phytotherapists will not normally receive a statement of the results unless the patient has obtained them and brings a copy. The lack of direct access to tests and their results distances the phytotherapist from this source of information, although it remains essential for herbal practitioners to recommend tests when appropriate and to take steps to access results when necessary.
Tensions arise in the relationship between history, examination and investigation as an effect of the types of knowledge they are considered to represent. The history and most examinations are considered to provide subjective findings, whereas investigations are designated objective. Objectivity is associated with ‘real’, whereas the subjective is considered suspect, debatable, open to question. Since medical science prioritizes objective information, the status of investigation as prime arbiter of diagnostic veracity has now been assumed. Although investigations do, of course, contribute to the understanding of patient’s situations (significantly and crucially in some cases), they remain an extremely limited means of knowing the patient. Despite this, such value has been placed on investigations that the phrase ‘treating the test results not the patient’ as an attack on over-reliance on tests is now in popular use. Numerous factors (individual, procedural, environmental) can lead to erroneous or misleading test results being given – investigations are not fault-free, nor are they all-encompassing. Investigations are rarely pathognomonic – they require interpretation and/or hypothesis-testing in practice. Concern has been expressed that the move to conduct routine screening investigations to test for the presence of pathologies in apparently healthy people may often be useless at best and sometimes harmful (Hadler 2004). It also remains the case that the vast majority of conditions presenting in general practice, as in phytotherapy, are diagnosed (or remain un-diagnosed) on the case history alone. Excessive, non-contextualized or unquestioning reliance on data derived from investigations can critically undermine the purposes of the consultation.
The consultation still tends to be taught to students of medicine and of phytotherapy as an orderly movement through history, examination and investigation. This is a grossly misleading preparation for the realities of practice and one of the great early challenges of fledgling practitioners is to adapt inadequate theory to the demands of unsupervised practice. We have already noted that investigation is not part of the consultation at all, since it is generally conducted: at a separate time to the consultation; in a different location; with another person! Additionally, investigation is normally employed infrequently, if at all, in chronic conditions. We have also said that physical examination is commonly neglected but even when it is fully utilized, it is rarely the most significant part of the consultation. That position falls consistently, and correctly, to the case history.
The consultation also tends to be taught as if the only encounter that practitioner and patient ever have is that of a first visit. In chronic conditions, where the patient sees the same practitioner over a long period of time (this is the norm in phytotherapy but has become less common for doctors), the greater challenge and skill lies in successfully using the potential of the follow-up visit to provide support and further advance healing. (We will explore this idea further in Chapter 5.)
The classical model of tightly structured case-taking, followed by physical examination and investigation is inappropriate to most patients’ predicaments and hence is quickly dispensed with by practitioners once they enter unsupervised practice. Rather, these three territories represent resources that the skilled practitioner combines and deploys as necessary. The case history remains the pre-eminent means of knowing the patient – and even that is badly named; perhaps we should just call it ‘the clinical conversation’.
Thus, the subjective domain of talking about, and listening to, the patients’ narrative and its contained hopes, wishes, desires, fears, impressions, concerns, insights, and so forth, provides not only the bedrock of the consultation but also most of its substance. We do not live or experience our lives objectively, nor can we get to know and understand people objectively. Objectivity is a method of abstraction and is valued in cultures where abstraction has assumed a dominating force. The origin of the word abstraction lies with the Latin for ‘to draw away’. Practitioners are exhorted to maintain a ‘clinical distance’ from patients when in fact the best practitioners draw close, carefully and appropriately to be sure, but close. Contemporary western culture has drawn away from nature, allowing it to be exploited to the point where the viability of human life on this planet is now at risk. The objective assessment of patients, when unchecked, leads to a consequent objectification of the person and is connected with the same trajectory of abstraction that has its origins in the western commitment to an unhealthy emphasis on science to the exclusion of other explanatory models. Although many commentators have criticized the medicalization of life it is important to recognize its origins in the scientization of life. Placing the subjective elements of the consultation at the centre of the consultation is a means of re-emphasizing the humanistic nature of medicine.
Since the mid-1990s, in the UK, herbal medicine practitioner education has moved out of the independent sector and into academic institutions of the state, i.e. universities. Many herbal practitioners have seen this as a sign of the success of the discipline and as a marker of its legitimization. Some other CAM disciplines have also made this transition. Opponents of CAM have railed against this development precisely because they too consider that incorporation of CAM courses into state institutions provides tacit legitimatization – a step that they consider unwarranted and which they invariably criticize vehemently. An editorial in Times Higher Education (2008) presented the usual litany pertaining to this issue – and a case study: ‘Opponents have derided CAM as ‘mumbo-jumbo’ that ‘no respectable university should provide’, ‘bogus’ and ‘the denial of rationality’ – and these are all criticisms that must be taken seriously … the University of Central Lancashire faced a revolt from its own staff, who claimed it was promoting ‘quackery’ by offering courses in homeopathy, acupuncture and herbal medicine’.
The reality is that when CAM courses are offered by universities, they are inevitably attenuated in some regard, although perhaps enhanced in others. When a CAM programme is poured into a university, it must necessarily fit the shape of the vessel that contains it. While independent educational courses in CAM are generally bespoke, tailored (more or less successfully) to fit the needs of specific groups of students, university courses usually introduce off-the-peg elements into the syllabus and its delivery: an existing anatomy module here, a generic ethics module there, and let’s throw in an existing research module or two. It is possible to cobble a CAM programme together quickly by adding the new students on to existing classes (in subject areas such as anatomy and physiology) and introducing a few new modules to account for the specific elements of the particular modality. Such courses tend to lead to a fragmented education and training that is lacking in a coherent ethos embodied in each module or element and which may, subsequently, compromise the integrity of the modality. If this is the case then the revolting staff at CAM-incorporating universities need not lose too much sleep – the straight-science rigor of the institution (if indeed it possesses such a thing) is likely to shape and pervade the CAM course. One risk is that students are rendered ambivalent, being partially exposed to two non-integrated approaches – that of biomedical science and that of the CAM modality.
Of course, delivery by conventional academic institutions may improve some aspects of CAM courses. Perhaps, for example, there will be improved criticality, greater insight through research, improved interprofessional activity (the usual claims to enhancement made by universities) but this is not a given, and they may not come without a cost. In any case pressure will come to bear on the approach, in our case phytotherapy, to fit, to some degree, the dominant biomedical model (since state institutions are usually not only imbued with the values of the dominant culture but also required to inculcate them). A process of appropriation of the CAM modality may then occur where it is gradually sculpted (by means of the application of various types of instrument such as staff changes, curriculum reviews, implementation of internal and national policy changes, accrediting and regulatory body edicts, etc.) to more and more closely resemble the icon revered by the revolting staff – re-made as a new, scientifically approved (and improved) product (‘Now with 20% Extra EBM!’).
State academic institutions will tend, then, to normalize CAM courses, which means to biomedicalize them. Although CAM therapists involved in running and teaching on such courses will try to protect the identity of their profession, this is only likely to remain in corners of the course, that is to say in certain specific modules where a reasonable degree of content and management control can be exerted.
The process of biomedicalization of herbal medicine had begun long before the incorporation of herbal education and training into universities in any case. Independent herbal practitioner courses have, for decades, taught conventional medical subjects such as anatomy, physiology, histology and microbiology. Yet they have always had the opportunity to tailor these subject areas to the particular needs, interests and perspectives of phytotherapists. When phytotherapy students are in the position of merely sitting-in on generic modules addressing these topics the scope for appropriate modulation, emphasis-placing and setting the locus of critique is much narrower. Phytotherapy has long incorporated biomedical subjects into the traditional herbal model but independent courses have been at liberty to do this on their own terms. The move to universities has reversed this position so that the control now lies outside of the herbal professions’ hands – biomedicine-based (and inevitably biased) university departments are now in the position of determining which elements of herbal medicine should be included in new biomedically-oriented herbal medicine courses.
There is a danger that herbal practice could now develop as a quasi-biomedical discipline where its practitioners ape general practitioners except providing a vegetable remedy in place of a synthetic chemical one. Many herbalists would accuse that this is actually a pretty accurate description of phytotherapy in its current state already. I continue to argue the case for a different perspective on phytotherapy, however as one which denotes (as discussed in Ch. 2) an approach to herbal medicine that engages with science and biomedicine while continuing the herbal tradition – but which is able to deal with all of these strands critically. Traditions of medicine should not be fixed – they must adapt and evolve or be consigned to the history books. Certainly there are perennial values and perspectives, which will remain as touchstones that define the herbal profession – these are the very aspects that should be defended and promoted – but much of value will be gained by keeping the doors of innovation and creativity open. The challenge for herbal medicine, in education, research, promotion and practice, is to make the case for, and to proselytize, its core principles and tenets while embracing and applying new information and techniques that increase its ability to benefit patients.
Herbal medicine can be practised in a manner that uses the consultation to arrive at or confirm a conventional medical diagnosis before treating it with an unconventional (i.e. herbal) remedy that nonetheless replicates conventional treatment, e.g. using a herbal anti-inflammatory in place of a pharmaceutical antiinflammatory. This is no bad thing as far as it goes – and if it means that the patient receives a treatment that is more effective and/or less toxic, then it will go a very long way indeed. Yet, herbal medicine offers much more than this – an alternative way of viewing the patient and her predicament, and therefore of helping her to adapt it, that includes a conventional diagnosis as merely one aspect of information and not necessarily the most significant one.
We have already suggested (in the preceding chapter) that the distinctive features of herbal medicine in this regard are shaped to a large extent by the characteristics and capacities of herbal medicines themselves. It might be useful to summarize and reiterate some of the features that arise from this view with regard to what is distinctive about herbal practice in profiling the patient and coming to conclusions about the nature and detail of her predicament. The herbal practitioner will:
• Pay particular attention to bodily systems and functions that are considered to be of fundamental importance in maintaining the integrity of the body, such as: digestion, elimination, immunity, nervous function, hormonal function
• Have confidence in her ability to address a wide range of conditions and features due to the huge scope of herbal medicines and their flexibility in being applied in numerous types of preparations to suit almost any eventuality
To further discuss what is distinctive about phytotherapy we need to name the relation that it can be distinguished from – this has to be the dominant medical form, biomedicine. In comparison with biomedicine then:
• The majority of herbal medicines possess a wide therapeutic window – meaning that any toxic dose is distant from the therapeutic amount and consequently a broad range of dosages are recommended by various herbal authorities. Pharmaceutical drugs have a narrower window – meaning that the toxic dose is relatively close to the therapeutic dose and therefore great precision is required in prescribing. The size of the safety zone for most herbal medicines means that the phytotherapist may take a more relaxed, looser, attitude to prescribing and be more willing to consider a degree of experimentation or trial in formulating and applying prescriptions to be not only ethical but essential to remedial success. This capacity, afforded by the plants themselves, may be reflected in a looser, more experimental approach to the consultation in general.
• Due to the close proximity of the therapeutic and the toxic dose the application of conventional drugs is closely associated with notions of risk and danger and their accompanying emotions – anxiety and fear. Since the greater percentage of herbal medicines are relatively benign the phytotherapist will tend to view her materia medica as a collection of subtle, safe and trustworthy entities that the patient should be able to entertain with confidence. While conventional medicines tend to be viewed by doctors as precision tools working on specific receptors, phytotherapists look upon their herbs as general systems adaptors. (This notwithstanding the fact that drugs can exert general effects and herbal constituents do bind to specific cell receptors.) If the classical concept of efficacious drug treatment in biomedicine can be illustrated as a magic bullet hitting the centre of a target within a terrified body then the herbal counterpart image is that of laying a healing blanket over a relaxed and resting body. The cartoon conventional drug is an incendiary device strategically deployed as part of the war being waged in the body during disease versus the equivalent herbal caricature of the mother embracing us and kissing away the hurt.
• Since herbs can do things that conventional drugs cannot, phytotherapists will look for things in the consultation that doctors do not. The propensities (seen in terms of actions here) of herbs which give rise to different ways of looking and acting include: the trophorestoratives, the adaptogens, the immunostimulants and modulators, the antioxidants, the nourishing nervines, the bitters, the circulatory stimulants, the aromatic digestives, etc.
We might formulate a list of words (Table 4.1) and their pairings that roughly distinguish the differences between conventional and herbal medicines with regard to their relative qualities and behaviours.
|Herbal medicine||Pharmaceutical drug|
These characteristics and properties are not confined to the remedy itself but they extend to mould the practitioner’s attitude and behaviour, her notions of what can (and cannot) be done with medicine, and how medicine should or must be done. These beliefs translate into forces that are played out in the consultation.
Medical textbooks on ‘clinical examination’ – a term that implies, and stands-in for ‘the consultation’ – typically follow the same format. ‘Clinical examination’ means ‘case-taking and physical examination’ and most books begin with a single chapter on case-taking (nowadays usually referred to as ‘the interview’) followed by 10 or 12 chapters dedicated to the physical examination of each bodily system (i.e. the cardiovascular system, the respiratory system, etc.). Within the (usually) solitary chapter dedicated to the interview, it is frequently stated that the interview alone accounts for 60–80% of diagnoses, which may seem odd given that most of the books allot less than 10% of their content to the study of this area. The meagre content that is dedicated to case-taking normally only covers the initial consultation, with only scant reference paid (if indeed any is given at all) to the purposes and techniques associated with follow-up consultations. Such textbooks are also almost entirely taken up (throughout their discussion of the interview and physical examination techniques) with considerations relating to diagnosis. Students learning from these texts could be entirely forgiven for coming to the following conclusions about the consultation:
This emphasis on diagnosis belies the reality of herbal practice (and, indeed, that of every other therapeutic modality). While diagnosis is an important factor in phytotherapy, it is only one among a number of other significant areas of exploration and work. Effort applied to discovering diagnosis is normally a high priority in the initial consultation but declines or disappears in subsequent ones unless substantially different symptoms arise. Over time then, in chronic cases, diagnostic considerations become of only minor importance. The areas that are more pertinent include:
Greaves (1996) locates the emphasis on diagnosis in the consultation with the primacy accorded to the treatment of acute cases and to hospital medicine:
The traditional account of medical decision-making … focuses on acute rather than chronic medical conditions and on hospital medicine rather than primary care. In doing so it detracts from medical work carried out with those suffering from chronic conditions, where establishing a diagnosis is only an initial and small part of the whole medical task, with assessment of progress, prognosis and amelioration of the condition being of far greater importance.
Summerton (2004) has underlined the elusive nature of classical organic diagnoses in general practice:
There are other problems associated with the act of making a diagnosis and the consequences and repercussions of this act. The stated agenda that underlies the pursuit of a medical diagnosis typically masks a number of hidden agendas with social and political import. Patients whose presenting picture does not match a classical diagnostic pattern may be negatively labelled, or indeed left un-labelled, in such a way as to effectively designate their suffering as invalid. Even when a diagnosis is attempted in such cases the particular label used may be one that is considered to be lacking in credibility, e.g. irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. These diagnostic constructs are sometimes referred to by clinicians as ‘dustbin diagnoses’, which is to say that they are repositories into which botched attempts at a proper diagnosis can be tossed.
The provision of a credible medical diagnosis validates the patient’s predicament as a sick-person and legitimizes their entitlement not only to statutory care and the consumption of related resources, and to exemption from work and family duties and other commitments but also to the sympathy and support of family, friends and the wider society. Conversely, the un-labelled (or unconvincingly labelled) patient is either barred from these privileges or granted only limited, and in which case probably grudging, access to them. Parsons (1951) described the valid patient as one who fits the socially defined ‘sick-role’ – the ultimate arbiter of this is the doctor and his primal act of power in conferring this role lies in the making of the diagnosis. A patient in possession of a credible diagnosis is said by Parsons to have both rights and obligations:
• The right to exemption from normal social roles and the right to be considered innocent in generating his condition (i.e. the patient is not personally responsible for his predicament and therefore should not be held liable for it)
The degree of entitlement to rights increases with the degree of severity of disease and the extent to which obligations are required to be met in order to retain access to rights diminishes with reference to how incurable the condition is said to be.
Patients who are not provided with a medically legitimate diagnosis may then be considered to be conducting themselves in a manner that is socially illegitimate and therefore socially deviant. Such patients will have none of the rights of the sick-person but, in order to attain a state of social conformity and thence potential social acceptance they must make extra efforts to attend to the obligations of the sick-person. Such attention may not be possible however, since, in the absence of a diagnosis, the doctor may be unable to provide the means for the patient to meet his social obligations – meaning that they may not be in a position to provide advice or treatment.
Arising out of this latter point, a further crucial relationship in the determination of the pivotal significance of diagnosis in the consultation needs to be emphasized. This is the relationship between diagnosis and treatment with regard to the curious fact that the one rarely exists without the other. Credible diagnoses are normally entities for which a treatment is available, regardless of whether the treatment actually works with any degree of reliability (consider cancer and its treatment). At least in conventional medicine, a condition that cannot be treated cannot be diagnostically conceived. New treatments may lead to the invention of a diagnosis or the substantial revision of an earlier diagnostic picture. Consider the manner in which the menopause was repackaged as a new zone of diagnostic possibilities with the introduction of hormone replacement therapy. HRT pathologized phenomena which were previously considered to be part of normal and non-medical life experience into symptom pictures which led to a medical diagnosis. In this case, the construction of the menopause as a disease to be diagnosed and treated was driven by corporate players (pharmaceutical companies) abetted by public demand – the locus of origination of the diagnosis was not within the medical profession but rather was imposed upon it. This illustrates that the notion of clinical diagnosis identifying a clinical need that eventually leads to the development of a treatment is not necessarily a reliable one. The process can, and does, happen in reverse.
A diagnosis only tends to be considered biomedically valid in the absence of the existence of a treatment when considerable organic lesions or morbid phenomena can be demonstrated, e.g. in motor neurone disease. Conditions that are lacking in consistently demonstrable organic lesions; where the morbid phenomena are relatively subtle or un-dramatic; and where no effective pharmaceutical treatment pertains (i.e. the vast majority of the human experience of illness) do not receive specific medical diagnosis and instead reside in the vast territory designated variously as ‘stress-induced’, ‘idiosyncratic’, ‘one of those things’, ‘hypochondriacal’, ‘all in the mind’, ‘self-limiting’. This position obtains to the extent that even when a patient exhibits extreme morbid phenomena (as for instance can occur in some severe cases of ‘chronic fatigue syndrome’ where patients may be bed-ridden and incapacitated for years) if there is no organic lesion and no treatment there will be no diagnosis and, consequently, no entitlement to statutory care or public sympathy.
If it were recognized that diagnosis often serves as a means of turning political complaints against the stress of growth into demands for more therapies that are just more of its costly and stressful outputs, the industrial system would lose one of its major defences.
In the last few decades, Illich’s use of the phrase ‘industrial system’ has seemed increasingly incongruous and dated to readers in the developed world as the phrase itself has declined in use. This decline may reflect several developments and agendas, including:
• The intentional identification, and disguising, of ‘the industrial system’ as belonging to a historical era that has now passed to admit a more benign age (when in reality the physical labour demands of the past have merely been replaced by an equivalent set of excessively depleting integrated physical-emotional-mental work demands: the call centre overtaking the factory).
We might therefore update Illich’s use of ‘industrial system’ with ‘economic system’ or ‘corporate interest’. In any case, the accusation remains that in uncritically diagnosing and treating conditions that arise as a consequence of unjust and inhumane economic agendas, the healthcare practitioner is complicit in enabling and maintaining those agendas. The correlate challenge is that healthcare practitioners should be both politically aware and politically active – politically aware in the act of diagnosing, and politically active in resisting providing a diagnosis that masks the politically derived aetiology of the condition.
One stunning example of how diagnosis can be formulated to accurately reflect the sociopolitical aetiology of a condition and to point up rather than mask the political nature and challenge of the phenomena is provided by the concept of karoshi used in Japan. Karoshi may be translated as ‘death from overwork’ and has been applied as a ‘socio-medical term in relation to workers’ compensation’ (Iwasaki et al. 2006) when it may also be taken to refer to disability arising from overwork. In the first few years of the twenty-first century, the Japanese Ministry of Health, Labour and Welfare, reinterpreted hundreds of cases of cerebrovascular and ischaemic heart disease as ‘labour accidents resulting from overwork (karoshi) …’ (Iwasaki et al. 2006). However, this was a development with a long history, since the relationship between sudden death and the Japanese production management (JPM) model had been noted and discussed since the 1970s (Nishiyama & Johnson 1997).
The designation of karoshi enables the causative factors that are absent in diagnoses such as ‘cerebrovascular accident’ and ‘myocardial infarction’ to be clearly stated. The genesis of the concept of karoshi lies in the extraordinary degree to which Japanese workers have been pushed to enable economic development. Iwasaki (2006) reports that: ‘in 2001, 28.1% of Japanese employees were working for 50 hours or more per week … much higher than those in European countries such as Netherlands (1.4%), Sweden (1.9%), Finland (4.5%), and Germany (5.3%)’. The eventual Japanese government recognition of overwork as the key aetiological factor in specific cases of cardiovascular disease was not a move of enlightened benevolence to the populace but rather one of economic pragmatism. The limit of overwork had been pushed so far that it was threatening to fundamentally destabilize the economy – a programme of compensation matched with measures to limit overwork was a necessary means of maintaining the economy. This case study illustrates how far a malign economic practice has to go before it is acknowledged by the state (it has, in fact, to become a threat to the maintenance of the state) and some degree of remedial political action is taken.
Seen in the light of the example set by karoshi, any diagnosis which omits to nail the key social, political or/and personal aetiological factor/s can be viewed as fudging the issue. While purporting to provide an insight into the patient’s condition the diagnosis then also typically conceals the true nature of the situation in:
The act of making a diagnosis is therefore not value-free and it has social and political associations and implications. Karoshi was above referred to as a ‘socio-medical’ term. We can suggest that diagnoses are always socio-medical terms and that the process of diagnosing is a politico-medical act. Practitioners may wish to avoid or deny these associations as a means of avoiding the consequent responsibility that comes with their acceptance but this represents a form of denial that is unacceptable given the duty of care owed to patients – because such denial crucially undermines the practitioners’ ability to cut to the quick of the patients’ predicament and to provide the deepest level of insight and stimulus to profound, transformative healing.
In phytotherapy practice, the patient has commonly (but by no means always) received a conventional medical diagnosis before attending, or is in the process of awaiting tests to achieve one. In such cases there is potential for the phytotherapist, as appropriate, to:
In seeking the patients’ views and perspective on the diagnosis, the phytotherapist is aiming to assess the degree to which the diagnosis is acceptable to the patient or not, and the extent to which she understands it. It is also crucial to gain the patients’ self-diagnosis and views on aetiology since insights provided here may lead the phytotherapist to suggest an alternative diagnosis based on the patients’ evidence.
In routinely questioning the conventional diagnosis it is not suggested that biomedical diagnoses are routinely wrong in terms of their own frame of reference, rather that they may occasionally be inaccurate or incomplete. The views of any fellow clinician should be respected but never uncritically accepted. Should the reliability of a conventional diagnosis be substantially challenged, it may be desirable for the phytotherapist to communicate with the physician concerned – such a situation is discussed in Appendix 3.
In assessing the patient, an alternative perspective on diagnosis and aetiology may have formed or presented itself to the phytotherapist. This may need referral for investigation to be further explored but might also, and more commonly, derive from a different take on the nature and processes of illness. This orientation will frequently leave the conventional diagnosis intact but speak to an alternative worldview that can co-exist with it. For example, in a patient with a diagnosis of hypertension a question along the following lines might be composed:
Hypertension represents a constriction of the heart and the arteries. This might relate to something – an issue, an experience, a worry or a fear – that you are tightly holding on to and that you need to open up and let go. Can you think of anything that feels like this for you?
In a case like this, the locus of the alternative perspective relates to causality and is not incompatible with the conventional diagnosis although, if the alternative aetiological view is valid it will tend to subvert the diagnosis or reveal it as inadequate. For example, if a case of ‘hypertension’ is due to fear, or holding on to a hurt that needs to be processed and released, then a more accurate, or more insight-rich, diagnosis might be framed as something like ‘cardiovascular fear response’ or ‘arterial hurt-holding phenomenon’.
Although phytotherapy students in the UK usually learn conventional medical examination techniques only, many practitioners later add study and training in alternative techniques to their repertoire – such as aspects of traditional Chinese tongue and pulse diagnosis. If these are present, then they will be an additional factor that might enable and inform the phytotherapist in offering an alternative diagnostic perspective.
Patients do frequently present to phytotherapists as primary carers, having had no assessment or diagnosis from any other type of practitioner. In such instances the phytotherapist should be simultaneously confident in her own capacity to assess and advise and be keenly aware of her limits to competence and the importance of appropriate referral to other practitioners.
Patients may also present with a firmly held self-diagnosis or they might be in possession of a diagnosis from another CAM practitioner or alternative diagnostician such as a vega-tester or iridologist. Wherever the diagnostic opinion arises from (the doctor, the patient, another practitioner or alternative diagnostician) the phytotherapist may find herself in accord or conflict, to varying degrees, with that opinion. Her personal beliefs, education, training, research and biases will colour her views and these should always be identified and questioned. The phytotherapist will hold general views that influence her perspective and these especially should be sought out and held up to the light for scrutiny. We might express such views and biases in the form of statements such as:
Each of these situations or factors presents a number of possible challenges for the practitioner. The phytotherapist will be best equipped to meet such challenges and consequently most able to assist the patient if she reflects on the dimensions and potentials of these situations and factors and questions her own beliefs, practices, behaviours and biases.
While diagnosis is classically related to an appreciation of symptoms and signs, the assessment will include the patients’ feelings, thoughts, behaviours, attitudes, aspirations and commitments. The diagnosis might be considered as providing a point of focus on which a prescription and management or development plan can be based while the assessment keeps in play all of the issues for more general or less immediate attention and which represent problems and potentials for future work.
In working with these two dimensions – both centre stage and behind the scenes – it is necessary to keep all factors continually or repeatedly in sight. The nature of the diagnostic-related working processes should match those that underpin the consultation as a whole, namely: holistic (taking a broad and inclusive view) and integrated (recognizing patterns and making connections).
A holistic and integrated approach must be able to accommodate and interpret a wide range of patient experiences, including those facets that do not fit classical diagnostic pictures. Such facets are sometimes referred to as ‘medically unexplained symptoms’ (MUS). Epstein et al. (2006) have researched and discussed the ways in which ambiguity generated by MUS impacts the consultation. They state that: ‘Dealing with ambiguity … increases the cognitive complexity of the encounter and physician anxiety …’ and suggest that: ‘In an effort to manage their own anxiety, physicians … either reject the patient’s symptoms (or ideas about causation) as not legitimate or collude with the patient’s proposed explanations and requests in an attempt to please the patient’. Each of these coping methods is problematic, with collusion proving little better than rejection, since it: ‘… may limit consideration of a wider range of diagnostic alternatives, whereas premature reassurance may paradoxically raise patients’ anxieties’. The authors further describe two varieties of communication style that are commonly employed in response to ambiguity in the patients’ case, these are: ‘usual care, in which ambiguity is denied and closure sought’ and: ‘a “partnering” approach in which the patient’s experience is understood, ambiguity is acknowledged, and patient input is sought’. This latter style is referred to as an example of patient-centred communication and it is suggested that additional patient-centred strategies will complement this manner of response, such as: ‘… coming to agreement on a name for the illness and a plan for follow-up visits, diagnostic testing, and treatment, recognizing that ambiguity about the nature of some symptoms may persist for months or years’. These various strategies are worth summarizing and elaborating as guidelines in dealing with situations wherein a concrete diagnosis cannot be given: