Abstracts

Introduction

Universal health systems, organised through primary health care (PHC), present better health outcomes, greater equity, and lower costs than those systems not oriented through PHC ¹1. McCarthy M . Health system report ranks UK first, US last . BMJ . 2014 ; 348 ( 25 ): g4080 . doi: 10.1136/bmj.g4080 .
https://doi.org/10.1136/bmj.g4080... . The strength of PHC lies in the achievement of its attributes: access, longitudinal care, comprehensiveness, coordination of care, as well as, family, community, and cultural orientation ²2. Rawaf S , De Maeseneer J , Starfield B . From Alma-Ata to Almaty: a new start for primary health care . Lancet . 2008 ; 372 ( 9647 ): 1365 - 7 . doi: 10.1016/S0140-6736(08)61524-X . . At the core of PHC is family medicine, where general practitioners (GPs) are responsible for providing and coordinating personalised and continued care to a cohort of individuals in a given territory ³3. Starfield B , Shi L , Macinko J . Contribution of primary care to health systems and health . Milbank Q . 2005 ; 83 ( 3 ): 457 - 502 . doi: 10.1111/j.1468-0009.2005.00409.x . .

Family medicine is a biomedical specialty which has historically challenged biomedical knowledge. For instance, in the United States, after the World War II, “the GI Bill of Rights... helped increase the specialisation of many who had been general practitioners (generalists) before the war” ³3. Starfield B , Shi L , Macinko J . Contribution of primary care to health systems and health . Milbank Q . 2005 ; 83 ( 3 ): 457 - 502 . doi: 10.1111/j.1468-0009.2005.00409.x . (p. 458). The restructuring of family medicine emerged as a movement contrary to the trend of super-specialisation in medicine. Through an international partnership, American general practitioners managed to stablish the required credential for a new medical specialty. From the 1970s onwards, postgraduate training became mandatory to practice family medicine in the US ³3. Starfield B , Shi L , Macinko J . Contribution of primary care to health systems and health . Milbank Q . 2005 ; 83 ( 3 ): 457 - 502 . doi: 10.1111/j.1468-0009.2005.00409.x . . In the United Kingdom, this opposition to biomedical knowledge can be understood in light of institutional rearrangements. In 1948, the inception of the National Health Service (NHS) strengthened the role of general practitioners. For instance, the College of General Practitioners, founded in 1952, sought to create an academic identity for general practitioners that was not simply “an attenuated version of hospital specialisms” ⁴4. Checkland K , Harrison S , McDonald R , Grant S , Campbell S , Guthrie B . Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract . Sociol Health Illn . 2008 ; 30 ( 5 ): 788 - 803 . doi: 10.1111/j.1467-9566.2008.01081.x . (p. 790). Thus, GPs’ core values have been gradually forged: starting in the late 1950s with Balint’s biographical model of clinical care ⁵5. Lakasing E . Michael Balint: an outstanding medical life . Br J Gen Pract . 2005 ; 55 ( 518 ): 724 - 5 . , endorsed by Engel’s ⁶6. Engel GL . The need for a new medical model: a challenge for biomedicine . Science . 1977 ; 196 ( 4286 ): 129 - 36 . biopsychosocial model of practice in the 1970s, and reaching the 1990s with McWhinney’s ⁷7. McWhinney IR . William Pickles Lecture 1996. The importance of being different . Br J Gen Pract . 1996 ; 46 ( 408 ): 433 - 6 . construct of “organismic thinking”. This effort to transcend biomedical model’s limitations contributed to develop a holistic approach in clinical practice. Holistic approach has been framed as “caring for the whole person in the context of the person’s values, their family beliefs, their family system, and their culture in the larger community and considering a range of therapies based on the evidence of their benefits and cost” ⁸8. Royal College of General Practitioners . The RCGP curriculum: core curriculum statement . London : Royal College of General Practitioners ; 2016 . (p. 44).

From the 1960s onwards, another movement emerged in Western societies that made a counterpoint to biomedical knowledge. Traditional and Complementary Medicines (T&CM) began to receive institutional support. Initially, the justification was to solve health problems of large population groups in the world, still in need of medical care. For instance, “in 1978 the WHO recommended that traditional medicine be promoted, developed and integrated wherever possible with modern scientific medicine” ⁹9. Helman CG . Culture, health and illness . London : Hodder Arnold ; 2007 . (p. 90). In the following decades, high-income countries have been experiencing an increase and consistent revaluation of T&CM with progressive institutional regulations. Scientific research on T&CM has significantly grown concerning its modes of functioning, efficacy, and safety. Two main reasons for this growth in high-income countries include: (a) dissatisfaction with biomedicine: greater iatrogenic effects, invasiveness, impersonal character, and mechanistic approach; and (b) virtues of T&CM: better care experience, stimulus to patient’s natural healing powers, philosophical and cosmological approach convergent with patients’ values, and holistic meaning of illness ¹⁰10. Gale N . The sociology of traditional, complementary and alternative medicine . Sociol Compass . 2014 ; 8 ( 6 ): 805 - 22 . doi: 10.1111/soc4.12182 . .

The growth of T&CM has substantially influenced numbers of physicians, including family doctors. The percentage of physicians who apply T&CM or work in partnership with T&CM therapists is considerable: (1) In Switzerland, 46% of physicians have some form of training in T&CM ¹¹11. World Health Organization . Programme on traditional medicine. WHO traditional medicine strategy 2002-2005 . Geneva : WHO ; 2002 . ; (2) In Canada, general practitioners provide 57% of herbal therapies, 31% of chiropractic and 24% of acupuncture treatments ¹²12. World Health Organization . World Health Assembly 56. Traditional medicine: report by the secretariat . Geneva : WHO ; 2003 . ; (3) In England, 50% of general practitioners in the NHS apply or indicate some form of T&CM ¹³13. Dobson R . Half of general practices offer patients complementary medicine . BMJ . 2003 ; 327 ( 7426 ): 1250 . doi: 10.1136/bmj.327.7426.1250-f . ; and (4) In the Netherlands, 50% of general practitioners prescribe herbal medicines, provide manual therapies, and acupuncture ¹²12. World Health Organization . World Health Assembly 56. Traditional medicine: report by the secretariat . Geneva : WHO ; 2003 . .

In Brazil, after the 1988 constitution, which set the bedrock of a unified health system, both family medicine and T&CM have nationally been fostered. The former via the inception of the Family Health Programme (FHP) in the 1990s. The FHP has evolved to become the main organising strategy of Brazil’s PHC ¹⁴14. Paim J , Travassos C , Almeida C , Bahia L , Macinko J . The Brazilian health system: history, advances, and challenges . Lancet . 2011 ; 377 ( 9779 ): 1778 - 97 . doi: 10.1016/S0140-6736(11)60054-8 .
https://doi.org/10.1016/S0140-6736(11)60... . The latter gained some visibility and growth after the 2006 National Policy on Integrative and Complementary Practices (NPICP), which initially supported five types of T&CM: homeopathy, acupuncture/traditional Chinese medicine, anthroposophical medicine, usage of medicinal plants, and thermal/minerals water. In 2017, there was an expansion of the NPICP to incorporate 19 integrative and complementary practices, such as: art therapy, Ayurveda medicine, biodance, circular dance, meditation, music therapy, naturopathy, osteopathy, chiropractic, reflexotherapy, reiki, shantala, integrative community therapy and yoga ¹⁵15. Brasil . Ministério da Saúde . Departamento de Atenção Básica . Política Nacional de Práticas Integrativas e Complementares - Informe Maio 2017 [ Internet ]. Brasília : Ministério da Saúde ; 2017 [ citado 20 Jan 2019 ]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/informe_pics_maio2017.pdf
http://189.28.128.100/dab/docs/portaldab... .

The diversity in national, social, economic, and cultural contexts has forged PHC services. This has resulted in several conceptions and organisational standards in PHC globally. However, one issue is consensual: the provision of clinical care. The clinical care role of health professionals is common to all PHC scenarios, which justifies and supports the scope of the present discussion.

This article aims to facilitate a mutual understanding between family medicine and different medical rationalities. It explores similarities between the philosophical foundation of family medicine and homeopathy as an example of T&CM. Ian McWhinney’s thoughts on family medicine and Samuel Hahnemann’s concepts on homeopathy are used for this purpose.

McWhinney, an English GP, developed his medical and academic career in Canada. One of the issues he addressed in framing the academic basis of family medicine was the peculiarities of illness phenomena presented to family practice. This has also contributed to the development of Patient-Centred Clinical Method (PCCM). The PCCM aims to improve patient care by valuing patient’s illness experience ¹⁶16. McWhinney I , Freeman T . Textbook of family medicine . Oxford : Oxford University Press ; 2009 . . Nevertheless, McWhinney’s ideas have not been widely applied and discussed within Brazilian (and, even international) PHC and Collective Health. A more familiar concept is Engel’s biopsychosocial model ⁶6. Engel GL . The need for a new medical model: a challenge for biomedicine . Science . 1977 ; 196 ( 4286 ): 129 - 36 . . This model displays a systemic framework for the biological, psychological and social dimensions in a hierarchical fashion such as molecules, cells, organism, person, family, biosphere, and society ¹⁶16. McWhinney I , Freeman T . Textbook of family medicine . Oxford : Oxford University Press ; 2009 . . However, Armstrong ¹⁷17. Armstrong D . Theoretical tensions in biopsychosocial medicine . Soc Sci Med. 1987 ; 25 ( 11 ): 1213 - 8 . states that “systems theory… maintains the dominance of the biological over the social” (p. 1214). In this sense, there is a convergence with contemporary discussions of Brazilian Collective Health that comprises both the expanded clinic ¹⁸18. Cunha GT . A construção da clínica ampliada na atenção básica . São Paulo : Hucitec ; 2005 . , ¹⁹19. Campos WSC . Saúde Paidéia . São Paulo : Hucitec ; 2003 . and the philosophical, ethical and technological aspects of health care ²⁰20. Ayres JRCM . O cuidado, os modos de ser (do) humano e as práticas de saúde . Saude Soc . 2004 ; 13 ( 3 ): 16 - 29 . doi: 10.1590/S0104-12902004000300003 .
https://doi.org/10.1590/S0104-1290200400...

21. Ayres JRCM . Cuidado e reconstrução das práticas de Saúde . Interface (Botucatu) . 2004 ; 8 ( 14 ): 73 - 92 . doi: 10.1590/S1414-32832004000100005 .
https://doi.org/10.1590/S1414-3283200400... - ²²22. Carvalho SR , Andrade HS , Cunha GT , Armstrong D . Paradigmas médicos e Atenção Primária à Saúde: vigilância da população e/ou produção de vida? Interface (Botucatu) . 2016 ; 20 ( 58 ): 531 - 5 . doi: 10.1590/1807-57622016.0410 .
https://doi.org/10.1590/1807-57622016.04... .

The biopsychosocial model has a built-in determinism within which an individual belongs to a level within the system. For McWhinney, it fails to “include a holistic approach” which stems from a “meticulous observation and understanding of the patient’s self” ¹⁶16. McWhinney I , Freeman T . Textbook of family medicine . Oxford : Oxford University Press ; 2009 . (p. 70). For him, the holistic medicine comprises patient’s wholeness and self-determination. Thus, it is possible to state that McWhinney was in search of an “epistemology of healing”.

In Homeopathy, Samuel Hahnemann was in the same quest. He contends that “the physician’s high and only mission is to restore the sick to health, to cure, as it is termed” and that “the highest ideal of cure is rapid, gentle and permanent restoration of the health” ²³23. Hahnemann S . Organon de la medicina . New Delhi : B. Jain Publisher Pvt. Ltd ; 1993 . (p. 85). Contrary to other T&CM such as Ayurvedic or Chinese medicine, homeopathy has a long presence in Brazil making it one of the most culturally accepted and easier to comprehend T&CM ²⁴24. Salles SAC , Ayres JRCM . A consulta homeopática: examinando seu efeito em pacientes da atenção básica . Interface (Botucatu) . 2013 ; 17 ( 45 ): 315 - 26 . doi: 10.1590/S1414-32832013005000010 .
https://doi.org/10.1590/S1414-3283201300... . Thus, it serves as a concrete “model” for the purpose of this article. Homeopathy allows a first exploration of McWhinney’s ideas towards T&CM, which, then, can also be exercised in relation to other medical rationalities. In this regard, the present article provides an organisational structure based on a gradient of explanatory models (EMs) to delineate the space within which T&CM can be better applied to patients’ care. Finally, it contends that family doctors and other health professionals working in PHC can provide a safe environment for applying T&CM.

Philosophical foundation of family medicine

Ian McWhinney (1926-2012), considered the founding father of family medicine in Canada, influenced this specialty worldwide. In the process of academically rethinking the specialty, McWhinney published a series of articles on the conceptual foundations of family medicine. As family medicine is not defined by an organ, gender or technology, it needed to reflect upon itself to delineate its academic content and practice ⁷7. McWhinney IR . William Pickles Lecture 1996. The importance of being different . Br J Gen Pract . 1996 ; 46 ( 408 ): 433 - 6 . . In 1978, McWhinney published an article questioning whether family medicine had reached the maturity required by science ²⁵25. McWhinney IR . Family medicine as a science . J Fam Pract . 1978 ; 7 ( 1 ): 53 - 8 . . In his view, the immaturity of family medicine stemmed from adopting biomedicine’s abstractions and presuppositions.

McWhinney highlights that abstractions’ organising nature can have unintended consequences. In biomedicine, pathologies have central and standardising role that dictates both medical practice and health research. This centrality not only limits and restricts medical work, but also permanently drive health professionals to think in terms of disease ²⁶26. Rosenberg CE . What is disease?: in memory of Owsei Temkin . Bull Hist Med . 2003 ; 77 ( 3 ): 491 - 505 . doi: 10.1353/bhm.2003.0139 . . Thus, the contribution of family medicine to biomedical science would be to question these abstractions:

Purposefully, McWhinney chooses psychiatry as an example of biomedical abstractions’ inconsistency. The indiscriminate prescription of psychotropic drugs demonstrates the problematic nature of disease-oriented practice in medicine. Psychiatric disorders, as a disease construct, are ontologically and epistemologically very fragile. Thus, the author proposes that family medicine should revise the concepts of disease and illness, “because it is in family medicine that we perceive most clearly the incongruities of our current system of abstractions” ²⁵25. McWhinney IR . Family medicine as a science . J Fam Pract . 1978 ; 7 ( 1 ): 53 - 8 . (p. 58).

In 1984, McWhinney published an article entitled “Changing Models: The Impact of Kuhn’s Theory on Medicine” ²⁷27. McWhinney IR . Changing models: the impact of Kuhn’s theory on medicine . Fam Pract . 1984 ; 1 ( 1 ): 3 - 8 . doi: 10.1093/fampra/1.1.3 . . The author compares Thomas Kuhn’s definition of “normal science” - an effort to put nature into its conceptual boxes - to physicians’ struggle to adapt individuals’ illness experiences into diseases’ framework. In this process, dissociation occurs between abstractions and concrete facts, producing what Kuhn calls “anomalies”. The accumulations of these anomalies would eventually challenge scientific assumptions, facilitating a paradigmatic revolution in Kuhn’s theory. The new paradigm does not necessarily deny the old but has greater flexibility to accommodate the phenomena formerly ignored by the old paradigm. For McWhinney, biomedical paradigm cannot deal with certain anomalies such as: (1) Illness/disease dissociation: many people who feel sick do not have a classifiable disease; (2) Specific aetiology: a causal agent cannot always be established; (3) Mind/body division: illness manifests as three-dimensional phenomenon, i.e., biopsychosocial; and (4) Placebo healing effect: abundantly documented in clinical trials (mean of 35% - ranging from 10 to 90%) ¹⁶16. McWhinney I , Freeman T . Textbook of family medicine . Oxford : Oxford University Press ; 2009 . . These anomalies challenge the implicit and inscribed idea of biomedical paradigm within which diseases are objects with autonomous existence, based on the occurrence of organic impairment in a chain of biological events, triggered by one or multiple causes ²⁸28. McWhinney IR . Why we need a new clinical method . Scand J Prim Health Care . 1993 ; 11 ( 1 ): 3 - 7 . . This mechanistic understanding of human nature reduces physicians’ task to that of repairing body’s organic impairment, i.e., the disease component ( Box 1 ). The biomedical-mechanistic paradigm completely obscures the effect of psychosocial and economic influences on the genesis and cure of diseases.

McWhinney’s organismic paradigm

McWhinney proposes a “new paradigm” for family medicine called “organismic” ⁷7. McWhinney IR . William Pickles Lecture 1996. The importance of being different . Br J Gen Pract . 1996 ; 46 ( 408 ): 433 - 6 . . It differs significantly from the mechanistic view of biomedicine. Box 2 highlights its main characteristics ⁷7. McWhinney IR . William Pickles Lecture 1996. The importance of being different . Br J Gen Pract . 1996 ; 46 ( 408 ): 433 - 6 . , ¹⁶16. McWhinney I , Freeman T . Textbook of family medicine . Oxford : Oxford University Press ; 2009 . , ²⁸28. McWhinney IR . Why we need a new clinical method . Scand J Prim Health Care . 1993 ; 11 ( 1 ): 3 - 7 . .

For McWhinney, the material description of diseases carried out by biomedicine is restricted to a physical level, or at most, the biological level of the human being. This understanding does not provide insight into the complex phenomenon of life, illness, healing, and death. The organismic paradigm stands out for its “multilevel” character and the possibility of “self-transcendence”. Existence, for McWhinney is multidimensional.

McWhinney is also influenced by E. F. Schumacher’s concepts on the hierarchical levels of existence. In Schumacher’s scheme, human beings are placed at the top of multidimensional hierarchy ( Figure 1 ) ²⁹29. Schumacher EF . A guide for the perplexed . London : Sphere Books Ltd ; 1978 . .

Figure 1 illustrates the immaterial elements that manifest at each level of existence: life (x), consciousness (y), and self-consciousness (z). For Schumacher ²⁹29. Schumacher EF . A guide for the perplexed . London : Sphere Books Ltd ; 1978 . there is an ontological discontinuity between each level. Following the same logic as Whitehead, the higher levels cannot be fully understood from the lower levels. For Schumacher, quoting Maurice Nicoll, “life, before all other definitions of it, is a drama of the visible and the invisible” ²⁹29. Schumacher EF . A guide for the perplexed . London : Sphere Books Ltd ; 1978 . (p. 43-4).

McWhinney seeks to prompt family medicine beyond the positivism and biomedical materialism, through both philosophy (e.g. Whitehead, Liebnitz and Schumacher) and epistemology (e.g. Kuhn). Without denying the scientific basis of medicine, McWhinney attempts a paradigmatic expansion of biomedical knowledge. This facilitates the dialogue with other ways of conceiving human beings and nature. The organismic thinking can be considered a watershed in biomedicine as it makes the biomedical paradigm more porous to other disease/health conceptions. It includes invisible (immaterial) forces that organise biological processes such as growth, regeneration, healing, learning, self-organisation, and self-transcendence. This understanding of the human beings yields a different approach to care, illness, and healing beyond the conventions of material biology.

The same cannot be stated about the techniques and therapeutic means used by family medicine. They remain firmly rooted in biomedical tradition with almost absolute preference to pharmacotherapy. The exception is the therapeutic usage of doctor-patient relationship. This context, however, can be improved. Other medical traditions and rationalities can expand the therapeutic scope of family physicians as they include other levels of human beings, as proposed by McWhinney.

The organismic paradigm, to the best of our knowledge, has not been fully explored. Despite its critic depth, the disease abstractions persist the main conceptual and interpretive tool of family medicine. As consequence, biomedical paradigm still dominates and captures the bulk of therapeutic interventions in PHC, resulting in disease-risk control and medicalisation ³⁰30. Tesser CD . Cuidado clínico e sobremedicalização na atenção primária à saúde . Trab Educ Saude . 2019 ; 17 ( 2 ): e0020537 . doi: 10.1590/1981-7746-sol00205 . . This adverse reality makes the discussion of the organismic paradigm very relevant as it opens the dialog with other contemporary knowledge and practices of health care. One of these possible relationships relates to homeopathy.

Homeopathy: Samuel Hahnemann’s vitalism

Samuel Hahnemann ²³23. Hahnemann S . Organon de la medicina . New Delhi : B. Jain Publisher Pvt. Ltd ; 1993 . (1755-1843) was a critic physician of the medicine of his time. He questioned the “old medicine” or allopathy, which sought to remove the “morbid” agent from patients by means of bleeding, vomiting, diuretics, and so on. For Hahnemann, this process aggravated patients’ suffering, by “depriving the organism of forces and fluids necessary for the heart” ²³23. Hahnemann S . Organon de la medicina . New Delhi : B. Jain Publisher Pvt. Ltd ; 1993 . (p. 11). Hahnemann advocated an eminently vitalistic conception of human being, as other physicians of the 18 ^th century ³¹31. Waisse S , Amaral MTCG , Alfonso-Goldfarb AM . Roots of French vitalism: Bordeu and Barthez, between Paris and Montpellier . Hist Cienc Saude-Manguinhos . 2011 ; 18 ( 3 ): 625 - 40 . doi: 10.1590/S0104-59702011000300002 .
https://doi.org/10.1590/S0104-5970201100... .

According to Hahnemann, the nature of disease could not be elucidated by analysing human body’s inner structures, i.e., its functioning, objectified in physiological constants and measurements. Health and illness resided in the vital principle’s dynamic-equilibrium state that characterises human beings.

Illness occurs due to an imbalance in the vital force or principle. The source of the imbalance may be at multiple levels of existence. The influences upon the dynamics of the vital force can be both external (relational, social and environmental) and internal (psychological, emotional, spiritual). This vitalist conception was abandoned by biomedicine from the beginning of the twentieth century ³²32. Waisse S , Bonamin LV . Explanatory models for homeopathy: from the vital force to the current paradigm . Homeopathy . 2016 ; 105 ( 3 ): 280 - 5 . doi: 10.1016/j.homp.2016.02.003 . .

Hahnemann conceived and developed a specific stimulation method of the vital force called pathogenesis ³³33. Rosenbaum P , Waisse-Priven S . Some remarks concerning homeopathic provings . Homoeopath Links . 2006 ; 19 ( 4 ): 214 - 7 . doi: 10.1055/s-2006-924443 . . Pathogenesis consists in administering of diluted and dynamized substances capable of altering the vital principle in healthy human beings, producing states of artificial illness. Hahnemann began the first pathogenesis in himself, in acquaintances, and relatives ³²32. Waisse S , Bonamin LV . Explanatory models for homeopathy: from the vital force to the current paradigm . Homeopathy . 2016 ; 105 ( 3 ): 280 - 5 . doi: 10.1016/j.homp.2016.02.003 . . This methodology was relatively known to the medicine of his time, but it had not been organised and systematised before him ³²32. Waisse S , Bonamin LV . Explanatory models for homeopathy: from the vital force to the current paradigm . Homeopathy . 2016 ; 105 ( 3 ): 280 - 5 . doi: 10.1016/j.homp.2016.02.003 . , ³³33. Rosenbaum P , Waisse-Priven S . Some remarks concerning homeopathic provings . Homoeopath Links . 2006 ; 19 ( 4 ): 214 - 7 . doi: 10.1055/s-2006-924443 . . The compilation of innumerable pathogenesis constitutes the “Homeopathic Materia Medica”.

Hahnemann’s coherence, rational, and scientific foundations towards the vitalist principle resulted in the homeopathic approach or healing art. This is characterised by four principles: (1) Pathogenesis - systematic experimentation and documentation of medicinal substances’ effects in healthy people; (2) The law of similar - similia similibus curentur - the process of selecting a medicine by the degree of similarity between symptoms produced in healthy persons (pathogenesis) and totality of patient’s symptoms, i.e., the “best match”; (3) Single medicine - to prescribe one medication at a time to be able to observe the remedy’s action on patients. A clear contrast to polypharmacy, common in his time, and a search for coherence with pathogenesis; and (4) Dilution and dynamization of medicines - the successive dilutions and dynamizations of substances reduced its toxic effects and, simultaneously, enhanced its curative principles ²³23. Hahnemann S . Organon de la medicina . New Delhi : B. Jain Publisher Pvt. Ltd ; 1993 . , ³²32. Waisse S , Bonamin LV . Explanatory models for homeopathy: from the vital force to the current paradigm . Homeopathy . 2016 ; 105 ( 3 ): 280 - 5 . doi: 10.1016/j.homp.2016.02.003 . . Homeopathic pathogenesis shows that even imponderable doses of medicines maintain active effects on sensations and functions of those taking part on the homeopathic pathogenesis. Paradoxically, little scientific research on pathogenesis has been carried out to date.

Hahnemann considered inappropriate to classify as chronic diseases those conditions resulting from daily exposure to preventable harmful influences ( Box 3 ). According to him, “these states of ill-health, which persons bring upon themselves, disappear spontaneously, provided no chronic miasm lurks in the body, under an improved mode of living, and they cannot be called chronic diseases” ²³23. Hahnemann S . Organon de la medicina . New Delhi : B. Jain Publisher Pvt. Ltd ; 1993 . (p. 161).

Hahnemann had a hierarchical conception of existence within which the vital force constituted an intermediate level between matter and the other levels of being.

This hierarchical cosmology of being coincides with both Hahnemann’s vitalism and McWhinney’s organismic thinking. In this hierarchical cosmology “‘higher’ always means and implies ‘more inner’, ‘more interior’, ‘deeper’, ‘intimate’; while ‘lower’ means and implies ‘more outer’, ‘more external’, ‘shallower’, ‘less intimate’” ²⁹29. Schumacher EF . A guide for the perplexed . London : Sphere Books Ltd ; 1978 . (p. 43).

Homeopathy is a complex and specific medical system that differs from biomedicine ³⁴34. Barry CA . The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches . Soc Sci Med . 2006 ; 62 ( 11 ): 2646 - 57 . doi: 10.1016/j.socscimed.2005.11.025 . . According to Luz and Camargo Jr. ³⁵35. Luz M , Camargo Jr K . A comparative study of medical rationatilies . Curare J Ethnomed . 1997 ; ( 12 ): 47 - 58 . , homeopathy is a medical rationality due to the following coherent dimensions: cosmology, medical doctrine, vital principle, morphology, diagnosis, and therapeutics. These dimensions constitute a medical rationality insofar as the art of healing has remained the predominant knowledge element. The commitment to heal or restore patients’ health constitutes the foundation of homeopathy as a medical rationality. Other medicines, such as traditional Chinese, Ayurvedic, and Anthroposophic medicines also share the same characteristics. Their integrating cosmologies of man, nature, and the universe are associated with the vitalistic principle. These medical rationalities combine micro- and macro-universe elements on illnesses’ genesis. Illness would be the consequence of an imbalance of material and immaterial forces. Human beings act at the same time as expressions and participants in this harmony rupture. To reach a new state of dynamic equilibrium, T&CM stimulates human beings’ endogenous potentials for rebalancing and self-healing in health care processes ³⁵35. Luz M , Camargo Jr K . A comparative study of medical rationatilies . Curare J Ethnomed . 1997 ; ( 12 ): 47 - 58 . . This approach facilitates a dialogue between family medicine’s organismic paradigm and T&CM as both conceptions transcend the biomedical model.

Different medical rationalities in primary healthcare

An organisational structure for implementing different medical rationalities in clinical care can be built based on a common understanding of illness phenomenon. In “Being a general practitioner: what it means” ³⁶36. McWhinney IR . Being a general practitioner: what it means . Eur J Gen Pract . 2000 ; 6 ( 4 ): 135 - 9 . doi: 10.3109/13814780009094320 . , McWhinney explains the differences between concrete and abstract thinking when caring for an illness. Diseases as biomedical abstractions offer taxonomic precision, correct application of biomedical technologies, great predictive and generalisation power. McWhinney contends that “the power of generalisation is gained by distancing ourselves from individual patients and all the particulars of their illness” ³⁶36. McWhinney IR . Being a general practitioner: what it means . Eur J Gen Pract . 2000 ; 6 ( 4 ): 135 - 9 . doi: 10.3109/13814780009094320 . (p. 136). Nevertheless, clinical care involves individualisation of concrete illness situations that extrapolate biomedical abstractions, i.e., disease classification. McWhinney explores the difference between disease as abstractions and illness as concrete phenomenon through a visual representation ( Figure 2 ). The original illustration was expanded to accommodate other explanatory models (EMs) ³⁶36. McWhinney IR . Being a general practitioner: what it means . Eur J Gen Pract . 2000 ; 6 ( 4 ): 135 - 9 . doi: 10.3109/13814780009094320 . .

Figure 2 illustrates nine distinct clinical contexts of disease/illness grouped in triads. The central parts of each clinical context represent disease abstractions and the irregular external part the illness phenomenon. Disease categories vary in their predictive and generalising power: high (square: solidity), medium (circle: fluidity), and low (spiral: volatility). For example, the first three squares represent the diagnosis of tuberculosis in which the biomedical model has great predictive and generalising power. The irregular area with different formats around each square illustrates the individualised and unique experience of illness. According to McWhinney ²⁸28. McWhinney IR . Why we need a new clinical method . Scand J Prim Health Care . 1993 ; 11 ( 1 ): 3 - 7 . , family doctors should include the illness dimension within doctor-patient relationships. This approach can enhance the curative effect of biomedical interventions by mobilising individual’s own healing powers and/or by improving compliance to proposed treatments.

The anatomopathological EM begins to lose strength as it moves towards physiopathological and semiological EMs. Physiopathological EM explains disease in terms of enzymatic, biochemical, hormonal, immunological changes, such as in asthma, allergies, hypothyroidism, arthritis, and so on. Semiological EM represents a very common occurrence in PHC. This illness context is rich in symptomatologic data but correlates poorly with anatomopathological or physiopathological biomedical EMs. This includes clinical contexts of medically unexplained symptoms (MUS), functional disorders such as irritated bowel syndrome, dyspepsia, pains (headaches, back pains), and mental health problems (depression, anxiety, etc). In summary, the gradient of biomedical EMs loses predictive power and generalisation as it moves away from well-defined (anatomopathological) towards poorly defined (semiological) clinical disease frameworks ³⁷37. Norman AH , Tesser CD . Quaternary prevention: the basis for its operationalization in the doctor-patient relationship . Rev Bras Med Fam Comunidade . 2015 ; 10 ( 35 ): 1 . doi: 10.5712/rbmfc10(35)1011 .
https://doi.org/10.5712/rbmfc10(35)1011... . In all these contexts, illness is present as concrete facts that individualise each clinical case.

This gradient of EMs has no clear cut and EMs may overlap. This does not invalidate the proposed framework as it aims to organise complex phenomenon. It seeks for resemblance, not precision, due to its practical nature. This gradient of EMs allows physicians to delineate spaces for including other medical rationalities. In clinical situations where biomedical model is hegemonic, the T&CM should have a complementary role. Nevertheless, in clinical contexts where illness lacks a robust biomedical EM (e.g. anatomopathological) that explains it, and/or where biomedical treatments have limitations, as in the case of mental health, other medical rationalities can gain in relevance. These medical rationalities utilise certain spectrum of illness information that has no value to biomedical clinical reasoning. In other words, the “mass of data about illness” ²⁵25. McWhinney IR . Family medicine as a science . J Fam Pract . 1978 ; 7 ( 1 ): 53 - 8 . can help other medical rationalities to elaborate different understandings of illness and clinical care plan. Homeopathic approach values patient’s information in terms of dream content, type of fears, certain attitudes (desire to be alone or in company, food aversion), body sensations (coldness, humidity, dryness, etc), triggers (weather or seasonal changes, loss of loved ones, loss of social position), feelings (sadness, hate, hopelessness), and so on. This data about illness contributes to tailor each patient’s treatment. The homeopathic empiricism shows that the most therapeutic similarity is that which is revealed mainly in the details and peculiarities of illness singularities. In other words, it operates as if the “best match” of remedy capacity of stimulating patient’s vital energy was dependent on a fine tuning with patient’s illness singularities. Therefore, it transcends the biomedical disease classification based on the commonality of symptoms, which neglects and eliminates that which is singular, individual, and subject specific. In the case of other medical rationalities, they may value other aspects of illness manifestations as well.

In family physicians’ PHC scenario there is a quantitative dispersion of clinical contexts that displays a continuum of clinical risk and severity ³⁸38. Rose G . Sick individuals and sick populations . Int J Epidemiol . 2001 ; 30 ( 3 ): 427 - 32 . doi: 10.1093/ije/14.1.32 .
https://doi.org/10.1093/ije/14.1.32... : low, medium, and high risk. The majority of patients seen in PHC has low to medium clinical risk profile, with low-risk predominating. These clinical scenarios are rich in symptomatology but are not easily framed into biomedicine abstractions, as in the case of medically unexplained symptoms. In this context of low or medium risk, family physicians may resort to drug prescriptions as mean for controlling patients’ symptomatology. This can expose patients to significant pharmaceutical side-effects and polypharmacy. Thus, especially in the low-risk, other medical rationalities or complementary therapies can be used, when it is culturally accepted.

This gradient of EMs ³⁷37. Norman AH , Tesser CD . Quaternary prevention: the basis for its operationalization in the doctor-patient relationship . Rev Bras Med Fam Comunidade . 2015 ; 10 ( 35 ): 1 . doi: 10.5712/rbmfc10(35)1011 .
https://doi.org/10.5712/rbmfc10(35)1011... , as an organising framework, allows to question evidence-based medicine (EBM) as the major criteria for validating the T&CM in universal health systems. Randomised clinical trials have a methodology that annihilates illnesses’ peculiarities and individuality ³⁴34. Barry CA . The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches . Soc Sci Med . 2006 ; 62 ( 11 ): 2646 - 57 . doi: 10.1016/j.socscimed.2005.11.025 . . Moreover, RCTs are best employed in settings where the biomedical EM is well established. Undifferentiated clinical scenarios tend to be excluded from clinical trials as biomedical rationality cannot explain the bulk of patients’ complaints. These excluded patients are usually the real and complex ones rich in symptomatologic data. Additionally, in individual clinical care there will always be uncertainty whether the intervention is effective for that patient. Therefore, one important guiding criterion in decision-making process concerning the use of T&CM is patients’ safety. For instance, it is not uncommon to unduly treat viral upper respiratory tract infections (VURTI) with antibiotics, despite being a benign and self-limiting condition. However, if other non-biomedical therapeutic options were available, it would be possible to reduce the misuse of antibiotics by providing an alternative to patients. This framework for applying T&CM in clinical contexts where biomedical EM is fragile, and patients’ safety is high, opens the therapeutic options for both patients and healthcare professionals.

Universal health systems can also reduce the commercial bias involved in T&CM since there is no out-of-pocket payments. The motivation for applying other medical rationalities is predicated on professional experience in relieving patients’ sufferings. Professional ethics should guide these therapeutic processes. Additionally, family doctors have the potential of not medicalise every expression of humans’ suffering ³⁹39. Illich I . Medicalization and primary care . J R Coll Gen Pract . 1982 ; 32 ( 241 ): 463 - 70 . . In some cases, providing undivided attention to patients’ complaints is enough to promote healing ²⁸28. McWhinney IR . Why we need a new clinical method . Scand J Prim Health Care . 1993 ; 11 ( 1 ): 3 - 7 . . Patients’ healing power is stimulated when individual’s life cycle, socioeconomic and cultural contexts are considered ⁴⁰40. Christie-Seely J . Working with the family in primary care: a systems approach to health and illness . Westport : Praeger Publishers ; 1984 . . Watchful Waiting is also another strategy as 40% of patients’ complaints spontaneously improve ⁴¹41. Rosser W , Shafir MS . Evidence-based family medicine . Hamilton : B.C. Decker ; 1998 . . Family physicians have a key role for incorporating different medical rationalities as they provide continuous and personalised care. The wealth of information obtained via contextualised understanding of each patient over time may enhance T&CM therapeutic effects. This also provides a safety net for possible adverse effects of T&CMs, which are admittedly smaller and less frequent than in conventional treatments.

A common argument against the plurality of medical rationalities concerns the structure, routines and organisational culture of PHC services. These are commonly biomedical oriented posing difficulties to other medical rationalities performances. For instance, homeopathy consultations usually require longer time which might conflict with standard shorter appointments of PHC services. This argument disregards two important issues. Firstly, 78% of Brazil’s Unified Health System services that offer T&CM occur at PHC level. Additionally, 20% of Family Health Strategy teams utilise some form of T&CM ⁴²42. Tesser CD , Sousa IMC , Nascimento MC . Práticas integrativas e complementares na atenção primária à saúde brasileira . Saude Debate . 2018 ; 42 Spe 1 : 174 - 88 . doi: 10.1590/0103-11042018s112 . . Secondly, the access to a personalised continued care and community-oriented practice, including home-visiting, provide different clinical care scenarios for a team-based care provision in PHC. Specifically, in relation to homeopathy and consultation-length, the longitudinal follow-up allows clinicians to elaborate with more precision patient’s illness symptomatic spectrum ²⁴24. Salles SAC , Ayres JRCM . A consulta homeopática: examinando seu efeito em pacientes da atenção básica . Interface (Botucatu) . 2013 ; 17 ( 45 ): 315 - 26 . doi: 10.1590/S1414-32832013005000010 .
https://doi.org/10.1590/S1414-3283201300... . This might facilitate the selection of homeopathic medication.

Despite the emphasis on family medicine clinical care due to its organismic thinking and homeopathic vitalism, the gradient of EM framework opens the space for changes to all PHC professions. The insertion of T&CM in primary care offers a potential for a team-based led care that could provide more diverse skills in handling patients’ illness, especially in mental health.

Conclusion

The use of T&CM is a fact in contemporary societies. It is possible to overcome the immature dichotomy between biomedical knowledge and other medical rationalities. The present organising framework, based on gradient of EMs, offers a point of convergence between the biomedical paradigm and other medical rationalities. This alternative and safe approach for implementing T&CM comprises three variables: (a) gradient of explanatory models for an appropriate T&CM insertion combined with assessment of clinical risk and severity; (b) professionalism and competence of family doctors to contextualise individual cases; and (c) provision of services through universal health care systems oriented via PHC principles, focusing on health promotion. This approach to T&CM can enhance family physicians’ task of helping patients to achieve a state of well-being.

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