The three C’s case analysis formula

The ‘apple’ analogy

The three C’s formula is woven into the clinical questions, case analysis, referral suggestions and treatment options for all cases studies presented in this book. To more

Figure 1 Dissected apple showing the three layers corresponding to complaint (skin), context (flesh) and core (apple core)

clearly illustrate this concept, we have likened the framework to the analogy of an apple, which consists of three distinct and purposeful layers.

1. The skin of the apple can be likened to the ‘complaint’, providing a first impression and surface information about why the client has come for help. This section shows us the cover that has developed as the underlying issues progress and manifest outwardly. For example, a feeling of fatigue is a ‘complaint’ symptom for which several reasons may need to be considered in order for it to be put into context.

2. The layers of physiological, environmental and lifestyle triggers of illness that are commonly shared or implicated in the development of conditions is the flesh of the apple, corresponding to the ‘context’. This flesh is usually significant and helps identify the cause of complaint symptoms, which may be common to a number of different individuals. For example, if a group of people with low thyroid function experience fatigue, then the shared complaint symptom of fatigue can be understood within a common context for that disease process.

3. The underlying issues at the heart of the apple make up the core emotional and lifestyle triggers that are unique to each individual. The ‘core’ of an apple houses the seed in the same way that we house the seed of our illness. This is where an understanding of the metaphysical/spiritual/emotional influences on illness plays an important role, with consideration that physical manifestations of disease have an underlying energetic or emotional beginning [13, 18, 19]. If unique stressors for individuals are recognised as the seeds that can develop into illness, the core section can be the gateway to understanding how to let go of the cycle of ill health and move towards wellness. The reasons an individual is vulnerable to compromised health are unique to that person and understanding those reasons is the key to holistic healing.

By using the framework of the three C’s formula it is possible to consider a case from a holistic perspective. If an individual is experiencing extreme stress due to their struggle to make life decisions based on their own values and beliefs rather than those of others (core), this stress may contribute to thyroid imbalance (context), thus causing the surface symptom of fatigue (complaint). In using this example we recognise the medical fact that hypothyroidism may cause fatigue and there is no biomedical evidence that hypothyroidism can result from the inability to make life decisions; however, chronic stress has been linked to the development and progression of a range of medical conditions including immune dysregulation [19]. It is therefore possible to see how chronic stress caused by an emotional conflict could trigger or worsen underlying immune-related thyroid dysfunction [19, 21]. We hope readers will be open to the concept of individual beginnings to common themes of illness. In offering this analogy as a suggested means of exploring individual cases, we are by no means suggesting this is the only way to perceive the causes of health imbalance in individuals with specific health conditions but rather suggesting that the three C’s formula framework is useful in holistically analysing cases.

Diagnosis

Each case in this book begins with a fictional case study including relevant medical investigations and physical examination history. We have deliberately limited information in the initial case presentation to allow readers to use their own diagnostic analysis skills to determine which specific questions are required to come up with a differential diagnosis list. To assist readers, a list of generic clinical questions is presented in Appendix A. A differential diagnosis list and working or confirmed diagnosis has also been provided. Although the title of each case provides the specific diagnosis, we encourage readers to go through the process of case analysis and come up with their

TABLE 1.1 MNEMONIC KEY

Referral flags and issues of significance

‘Referral’ and ‘issues of significance’ flags are included in the decision table for referral to indicate symptom priority. Referral flags are symptoms that indicate the possibility of serious organic disease or the potential of harm to the client, and which require immediate referral to a primary healthcare practitioner [3]. ‘Issues of significance’ symptoms are not as urgent as referral flags but still need to be addressed. These symptoms may be benign but could also indicate more serious conditions and may require referral and collaborative case management at some stage.

Integrating CAM modalities

In the experience of the authors, integrating more than one CAM modality into an individualised treatment program often brings superior results to using a single modality only. For example, nutritional therapy often combines well with herbal therapy and may be further augmented by incorporating a physical treatment modality. This type of integrative treatment approach has been used as the basis for the treatment recommendations in this book. Treatment suggestions are adapted to suit the needs of the individual client, taking into account factors such as financial status, likely compliance and the client’s individual preference for particular treatments. A variety of options is offered in each case, but it is not necessarily assumed the client will take all of the supplements recommended. It should also be understood that if a particular treatment modality has not been included we are not implying it is not appropriate. The range of treatment modalities practised by CAM practitioners is wide and varied and we have therefore chosen to include treatment modalities that are common to most CAM practitioners. We strongly encourage individual students and practitioners to consider treatment options in these cases from the perspective of the modalities they are studying or practising. These treatment suggestions are based on the specific needs and circumstances of the client and are not intended to direct readers to follow prescribed herbal formulas and supplements for all similar cases they encounter in their own practice.

Integrating CAM and conventional medicine

We acknowledge that several CAM modalities do not require orthodox medical diagnosis in order to effectively treat clients [4]; however, our book suggests a way this can be incorporated into healthcare management that provides benefits for both mainstream and complementary medicine. Integrating these aspects has the potential to enhance holistic diagnosis and treatment options along with providing an opportunity for positive collaboration with mainstream medical practitioners and allied health professionals [14–16]. Indeed, failure to detect underlying pathology may result in the progression of an illness into a more serious organic disease [3, 14]. As integration between CAM and mainstream medicine continues to unfold, mainstream medical practitioners are now more likely to train in areas of complementary medicine [16, 17, 20], and CAM practitioners may have additional training in an aspect of conventional medicine such as nursing, physiotherapy or medicine itself [3].

The referral recommendations in this book are not intended to fit every CAM model, and we recognise that CAM practice has various levels of primary care status globally, which will inevitably influence the priority of referral and which symptoms can be treated. We believe we are offering referral suggestions that include the varied legal and professional boundaries of CAM practitioners by encouraging referral that embraces the concept of open support from allied health professionals. These cases do not set out the definitive way to approach case management; rather, we present the idea of referral within the context of professional boundaries that focuses on the best interests of the client, who may want to be better ‘informed’ from a variety of perspectives regarding diagnosis and treatment options [7]. Achieving this balance can be difficult, and effective cross-referral and collaborative case management is reliant on the willingness of all health professionals to be open to different paradigms of health [3, 7].

We define collaborative referral as a referral from one healthcare practitioner to another, with the intention of shared care within the different areas of knowledge and expertise of each practitioner. We define cross-referral as referral from one healthcare practitioner to another when the referring practitioner discontinues care and effectively hands over treatment of the client to the other practitioner.

Because fundamental paradigms and methodology can differ so significantly, clients and practitioners may find diagnostic and treatment information from a range of perspectives confusing and conflicting [3, 4]. However, discussing the various perspectives and concepts with clients can be a positive experience for both the client and the practitioner if open communication is achieved [3]. Often genuine clarity comes with inner debate, reflection and questioning, and personal growth can be embraced through illness [9]. We believe that through this process clients can gain a clearer understanding, which can inform their personal choices as they make decisions about treatment and their journey towards wellness. Therefore, collaboration between healthcare practitioners can provide clients with a much more effective outcome [2, 7] and increases the likelihood of meeting all of the client’s needs [2]. Holistic healthcare is far more than using a variety of CAM modalities but involves collaboration and cooperation between all of a client’s healthcare practitioners [2, 6]. It is encouraging to note that recent Australian research has revealed medical practitioners are now more open to accepting the role of CAM practitioners in overall healthcare [3, 6].

The diagnostic and decision-making framework in this book can help readers become more confident in making sound treatment decisions by means of thorough analysis of the client’s case history and individual needs. This is an area of weakness for some CAM practitioners, as highlighted by a 2005 La Trobe University report [3] that identified a number of risk areas for Australian naturopathic and Western herbal medicine practitioners. These risk areas include: poor prescribing; failure to recognise contraindications; inappropriate dosage and duration of therapy; lack of understanding of drug/nutrient/herbal interaction; failure to detect underlying pathology; misdiagnosis; failure to refer; and failure to disclose or offer informed consent [3]. This could be considered the responsibility of the practitioner and, in response to these concerns, we hope our book will offer students and practitioners effective tools to ensure higher standards of clinical care and treatment.