Prātiniyamikīsiddhi – What success in clinical practice means

Prātiniyamikīsiddhi – What success in clinical practice means.

What do you mean by successful clinical practice? A prescribed medicine if it results in marked improvement of the patient’s condition, it is usually celebrated as success. But It is fascinating to understand that, this kind of clinical success is not accepted by classical ayurvedic texts and they categorically dismiss it as mere accidental or yadrucha sidhi¹. The current ayurvedic community is not giving much attention in discussing the Intellectual rigor shown in the classical tradition of Ayurveda in defining success in clinical practice. A Deeper study will completely change our perspective of what clinical success is in Ayurveda.

 Punarvasu Athreya was encountered with a very strong criticism when he opined that the clinical practice becomes successful when all 16 qualities of chatushpada come together². Two kinds of skepticism can be seen discussed regarding clinical success in Ayurvedic texts. One is Internal- from within the system raised by Agnivesa³ and second is external – raised by Maithreya as someone from outside the system.

 Nature of these discussions, where text gives ample scope for criticism and skepticism in defining clinical practice, clearly indicate the inclusiveness of Ayurveda. Here an effort is taken to understand how clinical success is defined in classical ayurvedic texts and how differently the current ayurvedic community should be working towards making ayurveda an evidence based medicine.

 Pausing a statistical question, Maithreya asks Athreya- why then even after the proper joining of all the 16 qualities, cure to disease does not happen in many cases? Why is there no consistency? According to him, Medicine doesn’t create a real impact on the outcome of a disease⁴. This is a perennial criticism faced by ayurvedic physicians even today that, results in one patient can not be generalized in a large population.    Discussion of clinical success is not completed unless both succeeded and failed cases are taken into account. Broadcasting the success stories powerfully and keeping silence regarding the failures is not a positive option. Unless the reasoning of failures is explained, one system can not be considered scientific. Accountability of failure is of prime importance and this is the first encounter a physician should be ready to face.  Questions regarding the absence of statistical correlation on cause and effect relationship are raised during this discussion.

This radical thinking has to be brought into the community of ayurvedic practitioners in order to establish Ayurveda as a credible evidence-based system. Random meaningless randomized control trials following the modern methods of research are not going to move far. Unlike the predetermined clinical guidelines created by researchers, which is just implemented by the modern medical doctors, the strength and power of Ayurveda depend on what happens inside the clinics of an ayurvedic physician. Medicine can be decided only when there is a clinical encounter with the patient. The evidence has to be created at clinics. As clinicians, one needs to keep answering these queries of  Maitreya and agnivesa.

 Being a true believer of Ayurveda, even after having no doubt regarding the efficacy of the system, Aagnivesa questions his teacher. Even though many are getting help from the medicines, few are not getting cured even after undergoing proper treatment as explained by the texts. Few others, without any management, get cured of their miseries. Thus Agnivesa doubts the consistency of the role of treatment. Are we skeptical enough to search for the reasons for failures? The system wants us to ask the same question even when we have many successful case stories. Answers from Athreya to these queries explain what really clinical success is.

 Pratiniyamiki sidhi⁵ is a term completely coined by chakrapani, the celebrated commentator of charaka samhita, while commenting on the definition of clinical success. Niyamam prati sidhi is nothing but repeatability. The same interventions in the right context will give the same effect and this should be the primary character of a successful clinical encounter.  

 The predictability of action of one intervention is another aspect chakrapani brings in while commenting on Charaka⁶. According to him, those who can not keep this repeatability and predictability are to be considered as quacks or kuvaidya. As the Gunakshara nyaya (where a worm even though makes a shape of a letter while it moves, does not suggest that it has knowledge regarding the letter), a kuvaidyais unaware of the reason of his success.

 Athreya tries to explain that a positive outcome of treatment is not the basis of clinical success. Without a supportive rationale (tarka), It is accidental and should be dismissed just as a chance. Both predictability and repeatability should be proved and supported with proper method of tarkaor ayurvedic rationale to amount to clinical success.

 What is the Tarka that defines clinical success? 

A structural and scientific way of analysis of the cause effect relationship should be in the background of every prescription and it is more important that it should be in the language of Ayurveda. Here are few examples to be considered while defining clinical success.

 Sadhyasadhyata, ayupareeksha, daiva vaigunya should be the primary consideration in assessing a disease. All diseases are not curable and thus the prognosis has to be assessed. A progressive disease gets cured only with a proper treatment and in self limiting diseases, treatment is an additional support.

 Natural course of disease.

Questions like what would have happened if no treatment would have been administered? Would the disease have been cured by itself? Would it have taken longer to resolve? Would it have worsened and become more severe? Etc should be considered while assessing clinical success. It is very important that we put forth right claims.

 What else could have been responsible for the improvement?

It should always be a question in a clinicians mind. Factors like diet, exercise, climate, atmosphere, or even a favorable mind will be the reason behind the actual cure. There are diseases that cure without any treatment.

 Did various medications have the same effect?

Same patient might be treated with totally different formulations and procedures by different physicians yet getting similar effects. This leads to doubts regarding the role of medicine and remains an alert for self limiting diseases or placebo effects. Charaka clearly explains the possibility of multiple medications for the same disease as the treatment is nothing but identification of specific condition and stage of disease and reversal by the suitable principle. There can be multiple medicines showing similar principles and it’s a duty of a successful physician to find out this principle behind treatment. Charakasamhita provides few examples of these specific principles which should remain as the focus of treatment⁷.

     In-depth understanding of Anumana provides excellent tools to create research methodologies that suit the system of Ayurveda to establish the cause and effect relationship and thus to generate evidence based on Yukti. Concepts like sahacharya, vyapti and paramarshaclearly differentiate association, correlation and causation.

Paksha, Vipaksha and Sapaksha resemble the concepts of trial drugs, negative control and positive controls to establish the causation. Right outcome measures are also important to establish clinical success. It should have all the three characteristics like avinabhava sambandha, avyabhicharitva and ayutasidhatwa to ensure sensitivity, specificity and challenge de-challenge.

 RTO (Retrospective Treatment outcome study), Prognostic and Outcome Method are few of advisable designs of research to generate evidence in ayurveda. It remains very near to the concepts explained in charaka samhita. 

 Diagnostic and therapeutic decision making should be scientific and systematic. Ama, dosha, dhatu, sthana, its vikalpa etc should be analysed in ayurvedic terms and should be considered systematically in decision making. This will bring in revolution in making ayurvedic treatment credible. It’s the ayurvedic clinicians who should come together to establish pratiniyamiki sidhi in each of their daily clinical encounters to lay the foundation for a database of evidence based ayurvedic medicine.

Dissecting the success stories with the proper method of tarka should therefore be regular exercise in the ayurvedic academy to produce evidence. That should remain the primary method of research in ayurveda. Laboratory experiments, RCT, and other modern research methodologies can act only as addons to make it more contemporary and communicable.

    Article Prepared by

    Vd. Jishnu Narayanan