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The Art of Knowing in Medicine How do clinicians know how to proceed? In what do they place their faith? Is it strictly a matter of evidence, or more empirical and intuitive? By Brad Lichtenstein, ND -- Fall 2008, Vol 4, Issue 13 Before focusing on her issues, Christy took a moment to tell me about the rash her 10-year old son developed three days ago after a routine tetanus shot. Within a few hours, small, red, raised, hot bumps began popping up two inches below the injection site. The next day, these bumps became confluent, and the itching grew incessant. Three days later, now, his symptoms continued to intensify. During Christy’s appointment, another patient left a message about her son, also developing a rash, but of a different nature. While playing in the backyard, this 12-year old boy rolled onto a rusty nail. He, however, had received a tetanus booster six months earlier. His trauma site was neither itchy nor swollen, but cold and surrounded by red streaks. One week after both of these events, I found myself speaking before third year naturopathic medical students in their case management class. I was interested in hearing their impressions about these two stories, given the little information with which I had to work. What is the first thing that goes through your mind? I was curious to know. Diagnoses and causes where tossed about – infection, MRSA, sepsis, expired tetanus vaccine. Some threw out suggestions of treatment, such as antibiotics or homeopathy. I wanted to explore their dynamic thought process, the complex philosophies that underlie every single assessment or decision they make, even while it may not be recognized or acknowledged. For instance, in the first case, MRSA sprang to mind among several students. This differential diagnosis is a piece of a larger algorithm of reasoning, such as questions concerning the sterility of the setting in which the vaccination was given and the needles used. If this shot was given in a community clinic or hospital, the risk of MRSA might increase. And if it were MRSA, the situation necessitated the use of stronger treatments, such as antibiotics, since natural treatments were less effective in severe situations, or so went one person’s rationale. For the young man with the post-vaccination reaction, I had prescribed homeopathic sulphur. I told his mom to give the potency she had on hand, which happened to be a 200c. The first dose she administered around 7 PM, and the next was given around 9 PM, right before the boy went to sleep. The next morning, the rash and all indications of its existence, had completely disappeared. When I spoke to the second mom, two hours had passed from the time she left the message. This woman, armed with an acute homeopathic emergency kit, had taken decisive action. Living in the mid-west, and not surrounded by readily accessible natural health food stores or pharmacies, I’d sent her this kit years ago, to help her in situations such as this one. This kit, or homeopathy specifically, she claims, saved her child from requiring antibiotics a dozen times. When younger, her son suffered from recurrent respiratory infections which resolved with homeopathic care. Unable to reach me about the rash, she did a few minutes of contrast hydrotherapy, alternating hot and cold, followed by a poultice of baking soda, then gave her son two doses of homeopathic ledum, renowned for healing puncture wounds. Within an hour, all indications of trauma were gone. Placebo, a few students mused. How do you know this wasn’t the placebo response? My reply, What if it were? Does it matter? What fascinates me more is this – would the placebo response even be considered had resolution occurred after antibiotics, or some other treatment were administered? Modality is not the issue I am questioning here; belief is. Where do we put our faith? With our scope of naturopathic practice and prescriptive rights expanding here in Washington State, I have witnessed providers opting for synthetic antimicrobial agents as a first line of defense for treatment of an array of conditions. For instance, a patient recently sought a naturopath for the treatment of his tinea corpus, or ringworm. After examination, the doctor prescribed ketoconazole cream as initial, primary therapy. When pressed by a shadowing student for a rationale, he claimed Why not use what works? With this comment and in one fell swoop, he invalidated the entire naturopathic armamentarium. I have heard from students, residents and practicing naturopaths that antibiotics, antifungals and the like are being prescribed with increased frequency. The belief being that synthetic medication works faster and better, that people lack the patience to wait for healing to take place, or physicians project their fears or wants onto the unsuspecting patient, such as when they claim the patient really wants a pill or if we don’t give them all these supplements now they won’t come back. RETURN HOME from Brad Lichtenstein's The Art of Knowing in Medicine |
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