Who Listens to the Doctor? Part 2

Doctors are trained to solve problems and to fix things. For much of what we do, this is an appropriate and helpful strategy. But for primary care doctors on the front lines with developing children and families, another strategy is needed. In a previous post, I wrote about an experience I had teaching young doctors in training. One intern proclaimed to another at the beginning of my talk that she would sleep through it. Instead, she was an active participant when she saw it was an opportunity to unburden herself of a difficult and painful interaction with the mother of a young boy.

This discussion I had with those young doctors made me think of a wonderful book by a Hungarian psychoanalyst, Michael Balint, called The Doctor,his Patient and the Illness. Following World War II, general practitioners in England found that much of their medical practice was consumed by addressing complex psychological problems. Out of this phenomenon there grew a research seminar to study psychological issues as they present in general medical practice. These later became know as “Balint Groups”, and consisted of a group of primary care doctors and a psychiatrist who facilitated the discussion. In the introduction to this book, in which Balint describes in detail the proceedings of his seminar, he writes:

The first topic chosen for discussion at one of these seminars happened to be the drugs usually prescribed by practitioners. The discussion quickly revealed- certainly not for the first time in the history of medicine-that by far the most frequently used drug in general practice was the doctor himself, i.e. that it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient-in fact, the whole atmosphere in which the drug was given and taken.

This seemed to us at the time a very elevating discovery, and we all felt very proud and important about it. The seminar, however, soon went on to discover that no pharmacology of this important drug exists yet. To put this discovery in terms familiar to doctors, no guidance whatever is contained in any textbook as to the dosage in which the doctor should prescribe himself, in what form, how frequently, what his curative and maintenance dose should be, and so on….in fact, the paucity of information about this most frequently used drug is appalling and frightening.

Balint groups are now part of many family practice training programs in the United States. The idea is similar to Balint’s original concern, namely to address directly the way in which a doctor, as a person with a relationship with a patient, is a critical part of the treatment. Offering oneself in this way can take its toll, particularly if a doctor is very good at it. The groups provide an opportunity to address not only the treatment of the patient, but also what it is like for the doctor when many troubled people unburden themselves of their deepest feelings. In many training programs for mental health professionals there are opportunities to talk with others about these experiences, in a sense allowing the clinician to unburden him or herself and therefore be open to listening to his or her patients. But for primary care doctors such an experience is the exception, not the rule.

As health care reform moves forward, finding a way to attract doctors in training to primary care will be critical. Appropriate financial compensation is essential. Understanding and respecting the "doctor as drug" concept is equally important in building a system that promotes a model of prevention.