ICR Operational Manual and Standardized Case Record

Dr M L Dhawale

Memorial Trust, Mumbai, India, 2003

(Price: Rs.250, contact: www.mldtrust.com;[e-mail]).

The ICR (Institute of Clinical Research, Mumbai) has used the Standardized Case Record (SCR) for training and clinical practice since 1970, and the Central Council for Research in Homoeopathy (CCRH) in India later adopted it, as a research tool. It is an extremely detailed, highly structured, and, it has to be said, complex 106-page 180×120 mm casebook for each individual patient.

It is ‘specially designed to allow the Homoeopathic Physician to record the data relating to patients in such manner that subsequently it is easily accessible to him. For this, a General Scheme is followed and each type of data is allotted a fixed position. It demands recording of symptoms in a classified (analytical) manner, which can be later synthesized according to the views held by Boenninghausen, Kent and Boger, who followed Hahnemann strictly in developing standard approaches to Totality, which have stood the test of time.’

It could be said to represent the highest ideal of systematic case taking for training and research purposes that could possibly be conceived, and I have nothing but an astonished admiration for the diligence of our Indian colleagues in using it. Homeopathy badly needs good, systematic and sufficiently structured methods for case taking and analysis that allow both reflective practice and data collection. Nevertheless, I doubt that the SCR will prove to be an appropriate tool outside India. It will be interesting to learn what use the CCRH has been able to make of it for research purposes, but the huge quantity of data in the record must make its collection and analysis a Herculean task, and I cannot see European, certainly British doctors being willing or able to adopt such a painstaking and possibly time-consuming method. We simply do not have the mind-set of our Indian colleagues for it.

The SCR is the brain-child of the late Dr ML Dhawale, one of the most renowned figures in the history of homeopathy on the sub-continent, and author of Principles and Practice of Homoeopathy, a book that deserves study by serious students of homoeopathy, particularly their teachers. It represents his profound and exacting knowledge, wisdom and discipline in case taking and analysis, and this is reflected in the Operational manual that accompanies the SCR. True to its title, the manual gives instruction in the use of the SCR, and explains its concepts. The chapters of instruction, together with the two detailed illustrative case histories will be of limited value to our students and teachers, because they can only be fully appreciated within the educational culture and teaching methodology for which they are written, and in which the SCR is intended to be used. But they are worth browsing at least for the breath-taking panorama they afford of the homeopathic anamnesis and approach to illness and healing, and some sections are worth reading in detail.

Of more immediate value, especially to teachers, are the earlier sections dealing with the underlying principles and concepts. On an page 7 it announces the essential truth of the homeopathic approach, that ‘A case well taken is a case half-cured’, and goes on to teach valuable lessons to that effect. But from the outset the manual emphasises that the homeopathic approach is only one part of the therapeutic process, and that a variety of ‘ancillary methods’ such as education, psychotherapy and diet, may have an essential part to play.

There is an excellent summary of 16 interview techniques (p. 25). Their range gives a good sense of the depth of thinking displayed in the book: Questioning (its dangers and limitations), Exploring, Listening (the most highly recommended skill), Observation, Blocking (to be used discriminatingly when the patient does not stick to the point, keeping in mind that ‘the diagnosis of irrelevancy could be highly subjective and we may throw the baby out with the bath water!’), Guiding, Assurance, Confrontation, Counselling, Silence, Informing, Interpreting, Refusing (some demands of the patient may not be consistent or appropriate to the aims and expectations of the consultation), Empathizing, Not accepting (the patient's world view—again a matter of fine discrimination and judgement), and Role-playing.

Another valuable section (p. 35) deals with the presence of an observer at the consultation with the trainee doctor, and the training of the observer for this role. I wholeheartedly endorse the comment that ‘the presence of an observer in the consulting room (is) the most effective learning circumstance for the physician as well as the observer’. This has certainly been the experience of some of my specialist trainees and myself. Vital insights have been gained into the strengths and weaknesses of the trainee's consulting and case taking manner and technique that would never have been gained from a verbal or written review of the case.

The later sections of instruction for the use of the SCR are, as I have said, worth browsing for the wisdom and knowledge to be gleaned there by our teachers. An example is the discussion of the concept of Totality (p. 145), which defines the following six ‘totalities’: Acute, Chronic, Intercurrent, Sequential—‘When we organize the mass of symptoms on the principle of homogenous blocks according to their evolution, it is sometimes possible to identify the sequence in which the remedial forces will be needed in cases with complicated symptomatology. The concept of the relationship of remedies comes into focus at this point’, Split totalities—‘In some cases with confused symptomatology, it is not possible to erect a homogenous totality. Then it becomes necessary to split the symptomatology into more than one totality and prescribe on the basis of the most prominent homogenous block’, and Related totalities.

There is an interesting Glossary, particularly of terms relating to the mental state. This is necessary for the accurate use of terms listed in the SCR, but is a valuable aid to the discussion of symptomatology in its own right, whether it be the meaning of ‘clammy’ or ‘fretful’.

All in all, the SCR is probably not applicable to European homeopathic practice, but although much of the Manual applies directly to the SCR, it also contains a wealth of material that I believe will enhance the repertoire of teachers throughout the UK and Europe, and I warmly recommend that each teaching center and each library obtains at least one copy.