Tuesday, 30 June 2020

Remote working and Homeopathy

Even before the COVID-19 pandemic, it was increasingly common for UK homeopaths to offer consultations via platforms like Skype, Facetime and so on. Problems with this have been touched on before in conjunction with CEASE therapy.

This post will look in more detail at some of these problems as well as discussing how homeopathic consultations differ from other forms of consultation and its suitedness to remote working. 

The homeopathic consultation differs from, say, a GP appointment in a number of key ways. The homeopathic consultation may appear to resemble a psychotherapeutic encounter but in reality, there are profound differences in both practitioners and goals (this will be discussed in a future post).

Homeopathic consultations are predominantly verbal. Homeopaths vary a lot in terms of the approach they take. Whilst there has been some academic study, it is limited and tends to be partisan but indicate that a less structured approach than other types of medical consultation. This could be a function of length - it is difficult to maintain a structured approach for an hour or more.

Physical examination
Western trained lay homeopaths tend not to physically examine patients. Some do use bizarre machines though. Some use applied kinesiology. Obviously, they can not use these devices but some may claim that their devices are capable of remote diagnosis. It is better not to ask about broadcast radionics. Homeopathic Facial Analysis (HFA) may be out as well.

Medically trained homeopaths may be more inclined to examine patients. DHMS/BHMS qualified practitioners from the Indian sub-continent may also be more inclined to examine patients - some of them pose in white lab coats with a stethoscope round their neck, others make a great deal out of medical tests, which they are not considered qualified to perform in the UK (they do not have a recognised medical qualification). A similar situation may apply for certain laboratory tests or referral for specialist tests.

Digital photography can be useful in remote examination. Video tends to be less useful because of its lower resultion but sometimes it is useful to see a patient moving. Technological advances have resulted in better and cheaper medical sensors. One good example would be blood glucose meters for diabetics and their results can be uploaded. Smart watches and other devices now offer routine monitoring of various vital signs such as pulse rate and blood pressure. Some of these devices are not as accurate as those used by clinicians. Partly because of inferior sensors and partly because they need to used in a certain way and consumers don't always do that. Overuse and incorrect use of certain devices can result in increased levels of anxiety.

Of course, this isn't relevant to lay homeopaths because they are not qualified to diagnose in the flesh, let alone remotely.

Non verbal communication
Non verbal communication (NVC) is a two way street. Whilst it is important in evaluating a patient, a practitioner's NVC can affect how a patient percieves the practitioner. There is research that shows a link between practitioner and patient satisfactory. In psychological therapies, NVC is an important part of active listeningMore generally, there has been an increased focus on teaching medical practitioners communication skills, especially those who encounters many patients face to face (it is less of a concern for, say, pathologist).

On the other hand, some of the claims about reading body language are overstated. Certain emotional states can manifest themselves physically but they can arise from a physical condition as well.

Tone of voice is tricky. Telephone/internet call quality can be poor and then there is the matter of having a base line to compare to. It can be difficult to pick up emotional queues from speech from someone you've never spoken to before. Some people find telephone/internet calls much more stressful than face to face interaction. Video calls may allow for picking up on facial expressions but again, there are issues of quality and not having a base line. For example, some people's neutral expression may look angry to others.

What communication skills lay homeopaths are currently taught is unknown. Research suggests that in the past there was no formal training. As far as can be told, none of the usual providers of training for homeopaths offer any additional courses in NVC or active listening, but that would not prevent a homeopath going elsewhere.

There is a tendency among some to think that lay homeopaths are naturally more empathic people and have good listening skills. Some of that tendency may be due to lay homeopathy being predominantly female and assumptions about women having better communications skills. In reality, most people of whatever sex have far worse listening skills than they think. There are plenty of homeopaths who display very little empathy. 

Language and cultural barriers
Increasing use of communications technology has meant that some UK lay homeopaths are now targeting foreign clients and not just British ex-pats. Brits tend not to be very good with languages, so some of those clients will be speaking in their second or possibly even third language. Fluency and vocabulary are obvious stumbling blocks. However, there are also cultural differences in how patients think about symptoms and conditions. There has been researching into different expressions of depression and anxiety. This US article is helpful.

In certain NHS contexts, an interpreter may be provided. Because of the multi-cultural nature of the NHS, it is possible that the NHS could find a native speaking clinician for the patient. This is particularly important when informed consent for treatment is required.

The business of informed consent and homeopathy is a tricky issue at the best of times. How can someone consent to a treatment that is fictive? Yes, they can consent to taking an inert sugar pill that contains no active substance that has not been demonstrated to have an effect greater than that consistent with placebo, but can they consent to a form of sympathetic magic? Doing that in a foreign language?

Cultural barriers can also extend to NVC. Gestures have different meanings in different cultures for one thing, even some facial expressions. 

Privacy, Confidentiality and Safety
Some homeopaths were working from home already to one degree or another. Telephone consultation has been around for a long time so in theory these issues should be understood.

As many are currently finding, working from home can have difficulties in terms of setting boundaries for other family members, particularly if they don't have a dedicated space. Distraction is an obvious problem but privacy and confidentiality need to be considered too. A child or spouse inadvertently overhearing initimare or medical information, for example.

For clients, many of the same problems apply but there is the additional issue of safety. There are signs that  lockdown has lead to increased domestic abuse. It might seem unlikely that a victim of domestic abuse would seek out a homeopath but it does happen. Abuse can be more subtle than most think, especially certain controlling behaviours. Being overheard saying forbidden things can lead to unpleasant consequences. Although not directly related, there have been court cases involving divorced parents arguing about treatment of a child - in particularly vaccination. Differences in option on treatment of children can lead to conflict. By extension, a partner who disapproves of homeopathic treatment could be hostile if it were going on in their own home.

The consultation space is supposed to be a safe place. A place where the client can be themselves. A place free from environmental stressors. If the client doesn't feel that they are in a safe place, they may not feel to disclosure. If their immediate stressors are present, they will be stressed.

Zoom has become very popular but it isn't terribly secure and some organisations have banned its use. 

International legal issues
Some jurisdictions take the view that the jurisdiction in which the patient is based has precedence. Often in such jurisdictions a medical practitioner would need to be registered in the patient's jurisdiction. This is the situation in Canada and the US - MDs need to registered with the State/Provincial board relevant to the patient. It's a recognised problem in the roll out of telemedicine.

Other jurisdictions take the view that where the practitioner is located takes precedence. The UK is like this as are some other European countries, although there can be complications when it comes to prescribing.

As has been been discussed before, in civil law jursidictions such as France, only registered medical professionals can practice homeopathy. In common law jurisdictions, anyone can.

Where things get really complicated is UK lay homeopaths dealing with clients resident in jurisdictions that require practitioners to be registered in that country and that country is a civil law jurisdiction, a lay homeopath would be acting illegally. It is likely that insurance would not cover them.

Insurance might not cover remote working with clients in (certain) other countries.

As far as can be told, none of the UK homeopathy associations have any policy or guidance on telemedicine (it's possibly hidden anyway as "members only" content). Other healthcare associations do and some even go far to see it as a particular competency that requires specific training.

It is possible that the COVID-19 pandemic represents a blip and levels of remote working will return to normal once all restrictions are lifted. Pandemics aren't predictable and restrictions may be in place for a long time. It is not possible to predict when the next one will come along. Hopefully the UK will be better prepared next time - and that would include the UK homeopathy associations.

The Society of Homeopaths will in particular have to do develop guidance because of it being a Professional Standards Authority Accredited register.

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