TALK : 50 TALK ON FOLLOW-UP

Transcription

1 TALK : 50 TALK ON FOLLOW-UP Hello and welcome. Today is our 50 th talk and the talk is on Follow ups. What is a follow-up? A follow up is what do we do after we have prescribed the remedy, after we have given the remedy. So what I do is: I usually call the patient back after one month in chronic cases. If the condition is serious or acute, I would like to see the patient back in a week or in two weeks depending on how acute the problem is. And the other thing is I leave instructions with the patients that they have to report to me immediately if there is any problem or any issue or any complaint they have in the mean time. So the question is: What do we see in follow ups? There are two important things here: The first is what has been the response to the treatment so far? Here we have an evaluation at a local level, at a general level, at an emotional level, at a sensation level, at an energy level, at a pathological level. So when the patient comes to me for a follow up, I give him a little questionnaire form to complete while he is sitting in the waiting room in which questions are asked: 1. How are you feeling since the last complaint? 2. How are you feeling in general? 3. How are your local complaints? 4. How is your emotional state? 5. What dreams did you get? 6. How is your energy on the whole? 7. Did you do any pathological investigations? Talk 50 Talk on Follow-up 1

2 And so these are the questions that are asked at all levels and he writes them. He writes them before he sees me. So this is a kind of scanning of what is happening at all his levels? And so we need to see is there any change at any levels? Is there a change in the energy, in the local level, in the emotions, in the dreams, in the sensation level, in the energy level. This is the first thing we need to observe in the follow up. The second thing we need to observe is: Is there any additional information that the patient gives us in the follow up. My colleague Dr Jayesh Shah says, he told me once. He says: Rajan, for me the case taking does not end with the first interview. It begins with the first interview.' So the case taking is a process of collecting information about the individuality of the patient that goes about in all the follow ups, it never ends actually. Just give it a thought. Case taking ends and therefore each time the patient comes we are getting additional information about him. Just by observation is one of the ways of getting it. What types of questions does the patient ask us? What does he want to know? How doubtful or suspicious he is? How trusting he is? Whom does he bring in during the follow up interview? Who does talk? The patient talks or the other person talks. What are the things the patient is concerned with in his treatment. All these things speak a lot about his individuality and helps us to add information about the patient. For example, you have given the remedy to the patient and the patient comes and says: Dr, I am absolutely not better. Your medicine has absolutely no effect.' Straight away before you ask him anything. The medicine has had absolutely no effect. This complaining, this lamenting, this protesting tone is information we can add about the patient which we might have not got in the first interview. Because there was no opportunity to complain or lament at that time. Or another patient Talk 50 Talk on Follow-up 2

3 may say, Dr till today there has been no change but I am quite hopeful, I am quite sure that your treatment is going to have an effect. This is a completely different energy pattern than the first patient. So the follow up gives you a chance to further observe the patient, to further understand him and may be modify your initial assessment or understanding of the whole case. The second thing we are looking for is new facts, new symptoms or phenomena. For example, an incident happened in his life, a situation happened, an exciting factor happened and then there is a set of emotions or dreams or delusions or whatever or physical symptoms that come up. The question now is: Whether it is still covered by the remedy we are given or is he speaking something else. For example : If we have given Magnesium carbonica to a patient and he comes in the follow up with symptoms of Magnesium carb, this is fine. But if he comes up with something very bizarre, something very strange, he says, I get dreams where snakes are falling from the ceiling.' A dream that obviously does not fit with Magnesium carb. Remember at the sensation level, it still might be the same. But obviously, apparently there is something different. So you got to investigate it, you got to take this dream to a level of sensation or it might be a physical symptom. For example: I had a case which I was giving Magnesium carbonicum and this girl (let me look) and this girl she developed a cough. And this girl would simply not respond to Magnesium carbonicum and then when I asked for the modalities of the cough, there were 3 distinct modalities: 1. Cough was definitely worse on lying down 2. The patient had distinct <at night, it was a dry cough at night, and dry cough on lying down 3. And there was an intense craving for ice cream And these symptoms did not fit Magnesium carb at all. So ultimately when we did repertorisation of the case: Talk 50 Talk on Follow-up 3

4 Cough at night Cough on lying down Desire for ice creams We got Natrum sulph and Natrum sulph helped her cough immediately and not only that but the patient subsequently need Natrum sulph as her remedy. So actually Magnesium carb and Natrum sulph are not that far away. So, to observe the physical symptoms and the characteristic, the mental symptoms and the dreams, everything and to see whether those characteristics are in the original remedy. For example, in the initial case, you thought that the patient is not demanding. And in the follow up, you see that he is very much demanding. Initially he didn't show anxiety. But in the follow up he shows tremendous anxiety. These observations should be noted for further confirmation and use. So we need to see what is coming up in the investigation and observation of the patient. Finally, a follow up is an opportunity to reassure the patient and to guide him as to how to observe himself and how to make lifestyle changes, diet changes and so many other factors. So the questions I asked him are: I am going to read them out for you are 8 questions: 1. How are the complaints you came with? 2. Are there any new complaints to report? 3. How has been your mood and state of mind? 4. Has any situation affected you or is there anything that is causing you stress? 5. Did you notice any change in the way you are dealing with stressful situations? 6. What dreams did you have in the mean time? 7. How are you feeling in general? 8. Please mention anything else that you would like to report or any queries that you might have. Talk 50 Talk on Follow-up 4

5 So these questions scan the different levels of experience and it hopefully encourages introspection of the sort that is most useful and focused towards an assessment of the action of the remedy. Now what are the different possibilities in follow up in remedy response? Let's try to understand that: 1. Which is a good possibility is: Amelioration at all levels. Here we see a significant reduction at physical symptoms as well as emotional symptoms and the general state of health. A kind of conventional that I follow that I derive from practice is that if a patient is significantly better at all levels and by significantly I mean more than 50 % better objectively as well as subjectively then I don't do anything. I just wait. Give nothing, give no medicine. But if the improvement is less than 50% then I usually repeat the dose of the remedy roughly once in a month. If the local symptoms are better but the general symptoms are not so much better, I still repeat the dose. I found that if I stop too early suppose the patient is saying I am slightly better, I am somewhat better and I don't give any more doses, I see that symptoms come back. So unless the patient says, I am really significantly better, more than 50 %.' I generally tend to repeat the dose, if it is a centesimal potency, roughly once in a month. Of course, LM or 50 Millisemal potencies are anyway repeated daily. Now one more possibility that exists is that - There is no change at all. In such cases, we once again have to evaluate the symptoms, the modalities, the mind state and the dreams. We need to observe more closely and check them Talk 50 Talk on Follow-up 5

6 again in the follow up. Paying greater attention to observations on how desperate the patient is. How hopeful or hopeless he is. How trusting or non-trusting he is. With these observations with more dreams, with more clarity of symptoms we need to see if the patient is coming back to the same or to a different remedy in terms of both symptoms as well as sensation. If he is coming to the same remedy then I normally tend to wait for atleast two or three months on that remedy. Normally I expect that if it is the right remedy there will be some change in a month, two months or a maximum of three months. If there is absolutely no change, then I might consider a change of potency of that remedy. But in this case, if we see a new symptom, a new indication for some other remedy, then we need to study it in much more detail. If things in the observation, in the follow up, if the patient is giving the history does not match with the original remedy. Then we need to re- evaluate the case and prescribe a new remedy. Let me give you one example of this: I saw a boy in the follow up, a young boy, I tell you... it is a 4yr old boy with allergic bronchitis. He is allergic to dust, pollution, artificial colours, milk, preservatives, various food items. Cough and breathlessness come quiet often and he has to be nebulized. He loves chocolates, sweets. The mother had described in the original case that he is very affectionate, irritable, attention seeking, inquisitive, very restless and hyperactive and very particular about cleanliness and he is quite fastidious. When his demands are not fulfilled he screams. He is very stubborn. He is quiet loquacious. Talk 50 Talk on Follow-up 6

7 In the mother's history during pregnancy: She felt the husband was not giving enough time to her. She felt lonely. She felt no one is there to take care of me. Nobody is there to ask me what have you eaten. She wanted to get out of the house. She felt trapped and caught. She felt lonely, insecure and helpless. She felt somebody might come and kill her. As if somebody pounces on her. And she feels, if this happens my child will be left alone. She wanted to run away. She wanted freedom. She wanted change. This was her history during pregnancy. So considering the restlessness of the child and this feeling of the mother wanting change and wanting to freedom, I gave the child Tuberculinum. Also a very restless and obstinate child. Now in a follow-up, sometime later, I asked her how is the child? Now she says, well Tuberculinum helped a little but now he has cough since one month. He is getting very wild. He becomes very stubborn. I said to the mother, Please can you tell me about this behaviour of the child?' And the mother says, Well you know what he did the other day? He locked himself up in the room and shouted from the window out to passers-by and to the security people downstairs...' he is shouting from the window of the room, he is saying, My parents are harassing me. Please help me. They are troubling me, they are torturing me.' He is shouting and the parents are doing nothing to him. And this is what he shouted to the security downstairs and the security people came up, the neighbours came to the house to see what is happening to the child and nothing is happening. He has just locked himself in a room and he is screaming. So this is the way, the child actually seeks attention. He is very hyperactive, very aggressive and likes always to watch things with fighting. So when I saw this kind of feigning, this kind of pretending, this kind of malingering, this kind of deceitfulness, then I understood that this is not covered Talk 50 Talk on Follow-up 7

8 by Tuberculinum and I gave him the remedy Tarentula hispanica with which he did very very well. And Tarentula as you know also is a Tubercular miasm very close to Tuberculnium. So many times in the follow up when you get additional symptoms. You need to check if the symptoms they fall into the same remedy or close or something you have to change. The 3 rd is, 3 rd possibility: Is 1 st possibility we examined is great amelioration 2 nd possibility, no change 3 rd possibility is that patient develops symptoms that he has in the past. We have all studied Hering's law of direction of cure, and we know that the reappearance of the old symptoms is a sign of healing. However I think that this is true only if along with the reappearance of old symptoms, the patient is feeling better on the whole and in his vitality. The recurrence of the old symptoms must signify a increase in the patient's vitality and that's how the old symptoms are coming back and with that he should feel generally better. And if this is so then we should wait and observe without doing anything because true healing is going on and it requires no interference. Another possibility is that: An aggravation of symptoms occurs. If an aggravation occurs, which might be due to centesimal potency or 50 M potency, we simply need to stop the doses and wait and watch. If the aggravation does not subside or is very troublesome and we have given it reasonable period of time for it to subside and it occurs, then what we need to do is to re-evaluate the case, to study the symptoms all over again, and to see which remedy is indicated. If it's an aggravation due to the remedy, and it's a good aggravation, normally the patient again feels better and this aggravation soon subsides on stopping the remedy and the patient gets into a better state of health than before. If this does not happen, there is prolonged aggravation and no relief, you need to re-study Talk 50 Talk on Follow-up 8

9 the case again. It was probably coincidental, or whatever but you need to study the case all over again. Another possibility in the follow up- Is that something acute comes up in the intervene period. Now if this happens then we need to re-evaluate the state in this situation to see if the patient needs the same remedy or a different remedy or a repetition of the same remedy in a higher potency or if the patient needs a same remedy or a different remedy at all. If it is a minor indisposition you can just let it pass or give the patient just a few doses of placebo just for some satisfaction and things will pass. But if it is something more than that you need to evaluate again. Let me give you an example over here: So this boy about 14 years old, he was on Calcarea carbonica, I think he was on LM 0/8 and he developed... one day he developed cough and fever. The fever rose very high about 103, 104 degrees and quite a paroxysmal cough. So in these acute cases, one thing that we really need to do is that we need to investigate, we need to find out the diagnosis. Why is the child having cough and fever? So we send this child for investigations and it turned out, he has high WBC high leukocyte count with a consolidation patch in the lung. So this is a case of Pneumonitis. And then at that time, we take the symptoms. And what is peculiar in this case is the child has a paroxysmal cough but it consist only of two coughs at a time. It's always two... this way. Second is the fever, the temperature rises in afternoon, always at 5 pm. The 3 rd symptom is that he has got thirst for small quantities of water often and 4 th is: he has a strong craving for fruit. And finally the pathology is the inflammation of the lungs or Pneumonia. Talk 50 Talk on Follow-up 9

10 When we put these symptoms together: Paroxysmal cough or consisting of two coughs Fever at 5 pm Stomach thirst small quantities for often And Food and drink, fruits desires And we found the remedy Phosphorus and Calcarea carb we didn't find in any of these symptoms really, not in most of them. And so during this fever, I gave him the remedy Phosphorus and within one and a half days, the child responded, the cough stopped, the fever went away and within 4 or 5 days his X ray showed a marked difference in his consolidation and finally he was alright. So during an acute we need to study. For example I have seen cases where during acute there is high fever. The patient develops an intense bitter taste in the mouth, there is a desire for very spicy stimulating food or refreshing things and fruit juices. There is tremendous weakness. So this whole picture that is available to you during the acute is far, far different from the chronic picture of the state. Here you need to take this as an acute totality. The mind symptoms, the physical symptoms, the cravings, the aversions, the local symptoms and give a remedy for example in this totality, it would be China. And for that time China helps and either the patient may stay with China but most probably after the acute, the patient goes back to the original remedy. Now this happens in some cases and it happens more often in children and it happens more often with certain remedies like Calcarea carb etc. which are very very slow and sluggish and do not have within them the range to combat the acute situation. And therefore another remedy comes at that time. So one has to be careful in an acute. Talk 50 Talk on Follow-up 10

11 Now there is another evaluation that happens in a follow up and that is usually at the end of 6 months and at the end of one year. At this time, I ask the patient 3 or 4 questions. 1. How are you since you have first come to see me? 2. In the last six months what has happened? 3. In the last one year what has happened? 4. What happened to your complaints? 5. What happened to your state of mind? 6. And thirdly, what happened to you at the deepest or the sensation level? This is very important to evaluate. 7. And you cannot ask the patient please tell me what happened to you at the sensation level? But the way to ask is to the patient is as follows: We take anything that the patient comes with. For example: the patient says that I had a little stress at work. So we say describe the stress. He says, the stress is because of deadlines or because of this or because of that. We say ok this is the reason for the stress. But now tell me what is the experience of the stress? And then the patient says well in this stress as if things are tightening around me, may be something like this. May be. And then you know this was the original sensation on which you have prescribed the remedy. It should be normally if the patient is better he should be having the same remedy, the remedy should be the same. So you say ok now this sensation that you experience, this tightening or whatever it is, you have felt it before, isn't it? He says, Yes, I am familiar. It is a very familiar sensation.' And then I ask him, Tell me to what extent has this sensation, is it any better than when you came first to me. patient will generally say yes it is better. And then you ask to what extent is it better, 20%, 30%, 40%, 50%. Now to the extent that this sensation is better, I consider that the patient so much healed. If this is 40% better, the patient is 40% healed. Talk 50 Talk on Follow-up 11

12 And then comes the final question, this change in your state or being, what difference has it made in your everyday life? Ok. So the meaning of this question is as follows: That if there are changes within you then these changes must become manifest in your outer reality also. If they are not manifested in your outer reality then I don't fully accept that everything has changed inside of you. And the patient basically replies that many many aspects of his life have changed because this sensation is less so he is able to go out more, he is able to experience freedom more, he is able to do this, do that. The same stressful situations which he couldn't face one year ago he is able to face much better now. It has much less impact on him now and he experiences more and more the freedom to be in this moment. That's what he says and that's the evaluation that we need at 6 months and at one year and may be at 2 years. Because, you know normally a chronic case, it responds to the treatment quickly, may be 1 month, two month, three months. You see by 1 year or 2 years to experience the change at the basic sensation level and to see the manifestation in that change in the person's everyday life. I will give you an case example: It is very interesting. Because I had...i saw a patient and she came to me long time ago, 2004, now 7 years ago and she had come to me with a problem of very intense headaches and bodyache that especially comes when she goes in a cold climate. And she had like you know Rheumatoid kind of a situation and she had taken so many treatments and what not. Now, when I asked her to describe the problem to me, then she described in many, many sensation words like as if something is twisting, as if something is suffocating, as if something is rising up suddenly, as if an explosion and so many words she used. And ultimately she described a lot of gestures of twisting and Talk 50 Talk on Follow-up 12

13 moving and so on and so forth and then she described her anger also as a sudden explosion and this sudden explosion of anger comes when she sees something wrong happening, some injustice happening and then she says I cannot wait. I have to just go and attack the person. I have to just warn the person, she says warn them, don't do that, don't do that. And if he persists then she says, I go for the kill. I don't care'. She even pushed a man under the bus because he was trying to abuse her verbally. Now this anger, this intense anger, this feeling of being wrong, this feeling of being victimised, this twisting and this sudden attack, all this pointed to the Reptilian attack and went to Naja which gave her a lot of relief. Now I saw her over the last 7 years and progressively I have seen her year by year, I asked her the same question to what extent has this experience reduced and then she would say 20% 30 % in two years it was like 40, 50 %, in 3 yrs 70, 80 % and after 4 years she was absolutely alright. And today I had a very touching experience when she came back to me and she said I just came to meet you because she doesn't stay in Bombay, she came just for a day and she says, I cannot leave without meeting you and I just came to say that I am not taking any medicine for last 2 or 3 years and I am perfectly alright. My entire state of mind is so much at peace. I don't have any problem with anyone now. No anger, no pains, no aches, no nothing' and she said that the interesting thing is that whenever I have even a slight pain or whatever I just connect with you, I think of you and I healed. So it's so interesting that I am not an agent for her for healing but even the dose is not necessary anymore. Just the thought, just the idea is enough for her to heal. So interesting, so this happens over a period of time and this happens to the extent of the patient has made progress. I don't ask him each time these questions but I ask him over intervals of six months or one year or two years. If the patient within the first six months does not show significant change or if he is worse. Then we need to review the case. We need to watch the review of the case. A review of the case is to look at the case in a completely new light. It's Talk 50 Talk on Follow-up 13

14 completely a re-evaluating a case, it's like a completely fresh case. And to kind of get rid of all our prejudice, all about the case totally. And this is difficult sometimes, many times in 6 months, one year you are so much used to the patient that you kind of you think you know him, you know the pattern so well, you can't think of anything fresh. So re-evaluation of the case requires that you need to get rid of all those ideas about the patient and think totally new. I'll give you a case example: Just the other day, I was seeing a patient. This was a young man about yrs old and I was originally treating him for a few years with the remedy Ferrum sulph with which he was showing some response but at the end of 2-3 years, I realized even the patient says, I am better but I am not happy. Something is not ok. He is not significantly better'. He is repeating the same complaint over and over again. So there is no point telling I am better and then saying I have this same headache. I am having the same leg pain, something is not ok. And I am still getting upset and I am still getting angry and I am still getting dreams.' No sorry you are not better. So this is interesting. So many times you see a patient who says I am better and he is not better. After three years, four years you still hear the same complaints in exactly the same way and the patient insists he is better, I don't believe it. Whereas there are patients who are really better but insist they are not better. This is also very interesting. There is another group. So you have to evaluate what is happening here. So this young man to whom I had been giving Ferrum sulph and I was not really happy with the response and I said to him, Let me evaluate him totally afresh.' And it was so interesting what came up. Because first of all he described himself as an anti-social. He said that I don't like to meet people. I don't like to go in company, I don't like a crowd. I just like to be myself. And I asked him at that point, I asked him a little bit about his nature and he says, I... this is interesting, he said, I tell people what to do. And they don't do then I tell them a very very bad consequences'. Talk 50 Talk on Follow-up 14

15 So one way at looking at he was threatening them. So I asked him and he said, for example, you know if my family wants to buy a property or invest in a certain stock or whatever, I tell them don't do it because this will be a disaster... I keep telling them that something bad will happen. And I try to this way them to something or try to make them do something by saying that something terribly wrong will happen. I kind of keep warning them all the time. I said ok. So this was not actually threatening that he would do something but it was a warning that some disaster was around the corner and therefore they had to take action very soon. This was the whole idea. So this kind of pure observation about the evaluation of the case is really an art of Homoeopathy. You got to hear very very carefully what the patient is saying and when you hear that very carefully you will see the same pattern repeat in different areas of the case. You will see clearly how accurately you are able to see the situation. So I ask him, What dreams do you get?' He said, I get dreams of earthquakes'. At this dream he said, I get recurrently'. Now how do we connect the earthquake dream about this threatening or warning. So I said, Tell me about the earthquake. What happens?' He said, Well, I see the building', he says, swaying from one side coming back to the centre, and swaying to the other side and coming back and I think something terrible is going to happen and the building is going to collapse'. And I say, What do you do then?' he says then, I run to my parents and my sister and I say get up you are too slow. Get up the building is going to fall here. And I get so irritated that they are not acting quickly'. So in the re-evaluation, it happened that first of all he is asocial, he doesn't like to be in a crowd, he doesn't like to be in a public. And the second symptom is he is constantly warning his people of disaster. So in this way the case built up over a period of many many observations in this case taking and ultimately I gave him Talk 50 Talk on Follow-up 15

16 the remedy Ambra grisea which has to do with a group which is a mammal thing, you have to warn the group that the predator is around, you are asocial. Ambra is very asocial in the Materia Medica, antisocial doesn't want to meet people, very very afraid of crowd and so forth, so many beautiful things happened in the case. I don't want to go there. But the idea is when you re-evaluate, you start on a fresh page. One way of starting on a fresh page is you start with that which is the most prominent thing in that moment. The most strange. It may be a dream, it may be an incident. I remember one case Probably you might have seen it or I must have shared it with you, it was a young woman with a huge cyst in the ovary, huge, and very painful cyst. I mean the gynaecologist said, immediate surgery is needed, it was a huge cyst, one of the biggest I have seen and very painful. And then I gave, she had tremendous faith in Homoeopathy and me, so she didn t want to do anythingelse and I gave her a series of remedies, I gave her Natrum muriaticum. I gave her God knows another 2-3 remedies, I gave her one from the chocolate family. I remember I gave her something else, something else and there was a lot of things. She said, at a delusion level, there were so many things'. She wanted Krishna, she wanted to marry God Krishna, she didn't wanted to do anything, she was quiet a psychological full story. I almost thought she was going crazy. She would talk non-stop, she would call 100 times it was all crazy. But then nothing worked. You see I gave her 3-4 remedies, it didn't work. So ultimately I sat down and I said, Today we are going to do something'. And I said Tell me whatever you want?' She said, I have a dream that a guy comes and he tries to take me'. I said, Tell me about that dream.' And then we went into the intricate part of that dream of how the guy came, how she had a house made up of glass, how he broke through the house, how he tried to pull her outside and then everything came, this open, close, covering, shell everything, ultimately she needed a mollusc, she needed Venus mercenaria and her entire cyst disappeared. It's one of the most amazing cases in my career. Talk 50 Talk on Follow-up 16

17 Again it's done not in the 1 st time, 2 nd time, 3 rd time but in the 4 th or the 5 th time after several, may be one or two years that I found a remedy for her. You have to watch very very carefully. The follow up is a great opportunity. These cases which do not find well are a great opportunity to find the remedy. May be even to discover a new remedy. Ok. The other thing in the follow up that we need to see are exciting factors. For example: in the middle of the treatment if the patient has gone for a tooth extraction or an injury or there is a severe grief, he may need an acute remedy for that situation. But if it is an exciting factor that is aggravating the patient s own state. He may have a repetition of the patients own remedy. You may have to evaluate very carefully. And what I also do is you do keep the patient with a medical kit with commonly used remedies and then I can advise what to take for example in an injury, I can tell them to take Arnica or something like this. Now there is one more situation where the local symptoms are better, are improving. The headaches are improving, the pains are improving. The joints are improving may be. But the general state of the patient is no better. Even after 6 months or 1 year. This generally is not a good sign, this generally means that the patient is acting locally and we need to look into the case again. Because very soon, this remedy is going to stop working. A partial remedy that is not going to stop improving the generals, is going to stop working very soon. You got to be ready and start looking around for the real remedy. The another possibility is that the patient is feeling better mentally and generally but his local symptom or pathology is increasingly progressive. Now this means whether of two possibilities. One possibility is that the option is in such a severe pathological state and one remedy is doing is doing is generally making him feel better. This is a very very rare case. More often I would assume that the remedy is itself not right because it is not touching the pathology. The Talk 50 Talk on Follow-up 17

18 right remedy has to touch all the levels - the sensation, the delusion, the feeling the fact and the pathological level. So one needs to re-evaluate this remedy again and may be find something else. So I want to share some of the experiences in my practice. One experience over long term follow up, I find certain % age of cases. I can't tell you what.. may be 30%, 40% a certain percentage of the patients remain on the same remedy for several, several years. I have seen patients remain on the same remedy for 25 years on the same remedy and it helps them each time. The patient is better after few years something happens, they come up and the remedy is absolutely the same. I will give you one example. I saw this woman aged 28, she came in 2007 and at time I gave her, what complaint did she have? She had right shoulder pain, right hand pains, she said, I cannot move my hand. I cannot do anything. It's a lot of joint pains that she had and other symptoms sleeplessness and so forth'. So the remedy that came for her at that time was Magnesium muriaticum. I gave her Magnesium muriaticum LM 0/6 with which she felt better and then she somehow discontinued her treatment within few months. 4 years later she appeared at 2011 and at this time she had pain in some joints, she says she cannot fold her fingers and the pains are better with movement, better gradually, and she says in her mood she is completely fed up with the sickness. I said to her did you have any stress. Because, normally if the symptoms have come back there must be some exciting factor. I always look for this. If there is a relapse there must be an exciting factor and then she says, Well I started a company with some colleagues with a lot of honesty, integrity and loyalty. And I really nurtured this company and I gave so much myself to the company I developed an emotional attachment to this company and then what did these people do when I wanted to leave the company? They filed the case against me in the court. Because they didn't want me to join another company, they wanted me to lose my reputation in the Talk 50 Talk on Follow-up 18

19 market. They kept a track on where I was going, what I was doing, they wanted to destroy my career'. And I said to her, So what experience did you have? What feelings did you have in this situation?' And she said, I felt betrayed by them. I felt that they completely broke my trust in them. I trusted them so much, I was so attached to them, so much emotionally attached to them and now they betrayed my trust. So ultimately this emotional need and attachment and the betrayal of trust is also a story of Magnesium muriaticum. So I gave her again Magnesium muriaticum and with which she is feeling better. So what I find is that in about % of the patients over a period of years, you find the same remedy over and over again. But on the other hand, some patients need a change of a remedy and I find that these are especially those cases in which we had probably not come to the exact remedy in the first case. But not coming to the exact remedy in the first place does not mean that the patient does not improve. What we often see is that with the not so right remedy the patient does improve. But this improvement is short lasting and so another remedy comes into picture. On evaluating the case, you find symptoms which are same as earlier but there are some symptoms which are new and they indicate another remedy. You are able to view the case in a different light. We change the remedy. That also helps the patient. So many many remedies here help the patient over years. So I have seen cases which stay over the same remedies and those cases in which the remedies have been changed over the years and the remedies have helped. In Homoeopathy sometimes this way of prescribing one remedy and then another one and another one is referred to a way of zig-zaging in a way to cure. Now I want to talk about some other aspects of the f/up. I am talking very much at random but some useful advice from practice. One of the things we do in the follow up is counselling. Besides evaluating i, we also counsel. And in practice such as mine where I see patients for many, many Talk 50 Talk on Follow-up 19

20 years together and I treat them, many, many times they often treat you as their counsellor also. And I think we are really well equipped to counsel the patient in terms of his life situation because we know his state. We know his perception and we know what is it that goes well with his sensitivity. Sometimes in the course of this, the patient himself comes to an awareness of his own sensation and perception and this is really useful to him. And it is also this perception that we use in counselling him. The other thing is about diet and exercise. I usually find that advice about diet, exercise and lifestyle changes is best given after the remedy has started working. Because you know to a large extent a person's cravings, aversions, addictions, habits are depended on his state. So advising him that these things are not right, does not help to change it because it is based on his state. Now with the remedy he comes down to this state and he changes his state to understand what is good for him that is the time we can put in him some advice about diet, exercise and lifestyle. The same applies to meditation. Meditation of course very very good for patients. But also I don't advice meditation. The first time around I see the patients. I wait for the time till when the remedy given to him has create a certain healthy space in which he is able to sit back silently and witness what is happening without his head crapped up with all the state manifestations. And at that time if he asks me, Dr what else can I do to help myself?' Then I advise them to do meditation or read such books as The Power of Now' by Eckhart Tolle. This also applies to positive activities. One of the main things of course that we need to understand that it is very important for a patient to find a meaning and a purpose to his life and to manifest his own potential and we must encourage the patient to do this. We also suggest avoiding of aggravating factors such as smoking, drinking, drugs, working late hours, working too much, taking too much stress etc. But many times when the state improves, the patient himself drops off Talk 50 Talk on Follow-up 20

21 these things or it is much easier for him to follow advice. In fact they often do it by themselves without any need of advice from us. Now I want to talk about one more aspect and it is what do you do if you reevaluate the case once. Didn't happen, twice didn't happen, thrice nothing happen? And then you are completely in a way stuck, in a way in a blind alley. There is nothing moving forward, you are moving round and round with the patient, you are not able to think. Your mind has stopped. Something is blocking you from taking this case further, and you can't think of anything besides what you have done. So in this case seriously suggest to refer the case to another colleague. I have colleagues in Bombay, I tell him you go to this person, please go to that person. Let me have his fresh evaluation. Sometimes I sent to a colleague from a method similar to mine or I may sent the colleague to a practitioner, I may sent the patient to a practitioner whose method is totally different from mine, to have a completely different point of view and different school with a different opinion. The patient often really appreciates this gesture of yours because he understand your sincerity that you don't want to hold him, that you are now able to think in his interest and I think this is far more appreciable than just holding the patient and going around in circles. I want to talk a little bit about some questions that some of my students have raised. Q: One of the questions is: How do we know that the patient is improving and up to what level is his improving. And how do we know that the medicine prescribed is right or not? Now in this most of it I have talked earlier but I would like to talk about something else here. It is very important to know about the placebo effect. Many times the process of case taking is very intense and creates just by its process, it creates an awareness and certain kind of healing. There is also the Talk 50 Talk on Follow-up 21

22 issue of faith the patient has in you, has come with to you. These are very important. And therefore it is important that when the patient comes and tells you for the 1 st time, I am better', it need not be necessarily that it is due to the remedy. It may be due to a host of factors including the faith, including the case taking process, or whatever, what we call as the placebo effect. So you have to got to be very aware of that. So every time the patient says, I am better.' You don't have to write it due to the remedy and stay with that remedy. Because very soon what happens is that this effect passes and the patient says, I am not better anymore and u assuming that his earlier relief was due to the remedy want to repeat the remedy, go higher with the remedy, stay with the remedy, be careful with this. So when the patient says after sometime I am not better, re-evaluate and see if it still works out with the same remedy. There you have to look at everything - the dreams, the physical symptoms, the rubrics and everything. On the other hand, I told you there are patients who are hell bent on saying, that they are not better even though they are actually better, so we have to be very watchful. And how do we know that the patient is really better? I think for me the basic criteria when I know for sure he is actually better is when his sensation level has changed. When his basic core sensation has diluted, has lessened in intensity, only then I can say that he is better. An improvement in his moods, an improvement in his headache is doubtful. When the patient s original sensation is diluted, changed or reduced, then you can say he is truly better. And generally that change will be reflected at all levels, at pathology, at local symptom, at emotional, at dreams, at delusional, at all levels it will be reflected. The need for the modern medicine if he is taking any and he is used to it, the need comes down. The frequency and the intensity of his complaint significantly reduces. So all these objective phenomena must be present in order than we are sure that the patient is better. Talk 50 Talk on Follow-up 22

23 I will tell you a little bit of a joke. I don't know if I should tell you. But Many of us have had this experience. That the patient comes back after a month or 2 months or 3 months and says, Doctor, I am so much better and these things happen sometimes in some patient to whom you have given a rare remedy and you are really waiting for the result. The first time you have prescribed whatever octopus may be. The patient says, Wow I am so much better and you are thrilled and excited. But just as the patient is leaving your consulting room.' He says, I have one doubt Dr., last time you gave me a one powder and you gave me a bottle of pills. I finished the bottle of pills and now what do I do with the powder? And that's when your face really drops because the powder had the remedy and the pills were placebo. And the patient has just taken the placebo and has kept that powder very safely with him the whole month and not consumed it. You don't know what to say. So these experiences sometime happen. So you have to be circumspect about your evaluation of the remedy. Don't get over excited, another question that is asked is: How long shall we wait for the remedy action to take place? Generally, in an acute condition, in an acute state this should happen in hours. But in case of chronic conditions, it takes months. In an acute situation, if it doesn't happen within a few days, something is not better at all. And then we have to really re-evaluate the case. Sometimes, in acute cases I make the patient to wait in the waiting room for half an hour or one hour and I except to see a change in that time in his condition. Like in fever, in migraine, in headaches, in severe pain. He should improve instantaneously. But in chronic situations, I am happy to wait for one month and if there is absolutely no change in a month then we have to reconsider the remedy or the potency. Talk 50 Talk on Follow-up 23

24 It also depends I think on what level the patient is coming to you at? If it is at a pathological level, then you expect to see a change in the pathological level first. If it is at an emotional level, then u see a change at an emotional level first. etc. What I need to see is a definite change in all levels. Just the patient saying I am better is not satisfying for me. I want to tell you a little bit more about this. Many of my colleagues, and this is interesting. And I observed when they show me video cases, you will also observe in seminars, in video cases, even in your private practice, what we tend to do or what I see my colleagues do is how are you? And the patient says, Well, I am better. So you are better? Yes. your moods are better? Yes. Your headaches are better? Yes. And so forth. So what the colleague is trying to do is to prove to himself and the patient that the patient is really better. You used to have more headaches earlier, it was intense, now it's is less intense, isn't it? You get less itching, now isn't it? The pain is somewhat better now, isn't it? Aren't your moods little better now? Can't you say you are looking better now, you are smiling, you were not smiling before. So you notice that. You notice that you are smiling now. So the colleague is bent upon proving himself and the patient that the patient is better. Very often I have seen this. Whereas I do the opposite. That's the hint I want to give you. When I ask the patient how are you and he says, I am better'. And I ask him, How do you know that you are better?' how can you say that you are better? What makes you say that you are better? In what way are you better? So what I am telling the patient is that he needs to prove me that he is better, I am not sceptical, I don't think that he is better, sort of thing. It's not really true. I want him to prove to me. The honours is on him to tell me that he used to consume 8 tablets of pain killers in the months before and in the last month's treatment he has taken 2. So he knows he is better, so he has to give me the proof and I have to hear that exact proof and not just subjectively feeling. The Talk 50 Talk on Follow-up 24

25 way he handles and says, the way he has the pain. Everything has to quantified to what extent it is better. Another thing that I want to tell you about this feeling better is sometimes. The patient goes a bit over board and he says, For example Let's assume it's a case of Cannabis indica and the patient felt heavy and closed, he felt claustrophobic and he felt everything was pressing in on him'. And I say to him, How are you now?' And he says, I am much better'. And I say How do u say that?' Now I feel open, I feel I am floating I am flying, I am experiencing freedom, I am just in the air, I feel light and I feel open'. Now this may be better for the patient but as far as you are concerned, he is the same. Earlier He was on one polarity of Cannabis and now he is on the other. So for me the patient feeling better is not meaning that he is better because his sensation is just opposite polarity of the same thing. So feeling better doesn't mean simply getting better but it is having the space, to be in the moment. It means an absence of a fixed sensation. In a healthy condition, in a healed condition, the patient does not experience any standard fixed sensation. He experiences the moment. He will be in the sensation of the moment, in the miasm of the moment, in the level of the moment. He will have the flexibility to move across the kingdoms, miasms, levels without getting stuck in many sensations or even if it is opposite. And the patient needs to express that in his healing, he experiences more space to be in the moment. A man I gave Mangifera Indica too expressed it beautifully. He said earlier he said, Every... the situation was a problem that got connected with all the entire pattern of my life and now I see a situation as a situation that needs a solution and I move on. Nothing becomes a problem that gets connected with my entire life story. That's the freedom I am experiencing. That freedom has no specific sensation.' Talk 50 Talk on Follow-up 25

26 So that's what we needed to hear in the healing process, many times the healing process is described, as a dilution of the earlier sensation. Earlier I used to feel tight, now I don't feel so much tight, this is good. That my sensation is diluted is good. But I am experiencing flying and floating, oh you be careful here. Also this dilution of sensation changes the way they live and the choices they make in their life.' I remember this beautiful case of this senior person, a senior man. I think he was about years old and he was running a factory that fabricated instruments according to the needs, according to the order. So this man's job was to create, to invent, to produce new machinery and he had to make machinery, according to the requirement. They would say this is what we need to do and this man would create the idea of how this machine would work and that was his passion. And he would just go against all resistance, all pressure in order to produce that thing. The remedy he got was Ruthenium. It's in the 5 th row about creativity and its one in the 8 th column which is against pressure. Creativity against resistance. Stubbornly creative, persistently creative. And he developed renal failure. He developed first a heart attack, followed by a bypass, followed by a renal failure. His serum creatinine was really going high. And when I gave him ruthenium, the first effect of course was that he was feeling better, his creatinine levels went down, his renal functions became normal but within a few months, may be within a year or so he said I don't have stress levels any. I don't need to be so stressed and so persistently creative. I feel I can take life easy now. Other people can do the job, and so at the age of 65 or so he retired, he closed down his factory, he spend time with his grandchildren. So the need, the compulsion stubbornly, persistently creative, it diluted down, it disappeared that should borne the sign of healing. So that he has the ability to react in the moment. These are the signs we need to see in long term follow-ups. Talk 50 Talk on Follow-up 26