The doctor as drug

Psychoanalyst Michael Balint said: “If you ask questions, you get answers, nothing else.” In his work with primary care doctors in post World War II London, where many patients had symptoms related to complex psychological trauma, he supported efforts to use the “doctor as drug,” encouraging these physicians to be fully present to listen to their patients rather than asking questions guided by a need to make a diagnosis.

I thought about this idea of the "doctor as drug" when reading two recent articles in the New York Times on the same day. The first, A Dry Pipeline For Psychiatric Drugs, bemoaned the lack of development of new psychiatric drugs. 

This is news that I would cheer for, if only our system of health care allowed for doctors to use themselves as the drug. What is needed is value of time and space for listening. In such an environment the doctor, (or I should say clinician, as today the caregiver is often someone other than an MD) can let the story emerge rather than being guided by a need to make a diagnosis, which is now more often than not followed by prescribing of psychiatric medication. 

For example, a recent study identified an alarming rise in prescribing of atypical antipsychotics to young children. 

Data from the inspector general's five-state probe indicate that 482 children 3 and under were prescribed antipsychotics during the period in question, including 107 children 2 and under. Six were under a year old, including one listed as a month old. The records don't indicate the diagnoses involved.

The very availability of such powerful drugs, that can quickly suppress symptoms, may actually act in direct opposition to careful listening and meaningful change.

The second article , A Powerful Tool in the Doctor's Toolkit, addresses the issue of placebo effect. It refers to the work of Dr. Ted Kaptchuk, director of the center for placebo studies at Harvard:

Dr. Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it is something that can enhance medical care greatly. Wise doctors and nurses already do this. They’ve found, usually just by personal experience, that their “everything else” — respect, attention, comfort, empathy, touch — often does the lion’s share of medical care, no deception required. Sometimes the prescription is just the afterthought.

Under the influence of Big Pharma and the health insurance industry this issue has gotten turned on its head. The pill has become known as the treatment, and the relationship- the respectful, careful listening- has become the "everything else." Balint and Kaptchuk wisely recognize that it is actually the other way around.