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.
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.
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.
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.
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.
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.
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.
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.
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.
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