A Doctor's Journal
Doctor and Patient
As soon as we have left the haven of medical school and textbooks, we learn to our bewilder- ment that there is more in treatment than drugs, diets and surgery. Some patients will not improve with correct treatment, others will get better on the wrong treatment; some come to us with deep gratitude when we know we have done nothing for them, while others are full of resentment though we have spent much effort and sympathy. Such imponderables as the patient's expectations and fears, the doctor's approach and attitude, and the manner of examination not only in- fluence but often outweigh the conventional treatments.
THE author—Max Clyne, writing recently in the Lancet—goes on to say that the doctor's Personality, or his 'bedside manner,' is commonly considered to be incidental, and outside the scope of scientific inquiry. He is quite right. There have been few objective studies of how the doctor be- haves and reacts during a consultation, though studies of patients' mental and bodily states, con- ducted in 'interview-experiments,' have been reported over and over again. Yet, as Dr. Clyne Says, people choose or reject a doctor less for his erudition (which they can hardly judge) than for his 'personality,' for that peculiar set of qualities that apparently make medicine an art. Patients and doctors alike, if the treatment of illness is to go well, have to suit each other. If the doctor's attitude and personal make-up are so important ill medicine, then it is time they were explored and appraised. If one-quarter of the money and energy and time which are now spent on physical re- searches were devoted to this kind of inquiry, .we should be a great deal wiser than we are now.
Dr. Clyne then gives an account, written with commendable honesty, clarity and insight, of how he handled one case of his own, a sick child. Al- though the child was the 'patient' to whom he Was called, the parents were also involved— indeed, in a sense, they were patients too. I am sure this is true in very many instances where the child is brought for medical advice—the illness is of a relationship rather than a person :, the relationship of mother and child, or brother and sister.
At a children's clinic it has happened to me several times that a child is referred with itching, and the itch, and perhaps the rash as well, has cleared without the child ever being seen at all; the mother is seen first, by herself, and she gets so much off her chest that the emotional tempera- ture at home falls, and the child gets better and never comes to hospital after all. This may not happen very often, but when it does it reminds one forcibly how essential it is to take the family as a unit.
Mostly, in fact, 'the patient' is a group of people Who are all in some way affected by 'the illness' —looking at it objectively, all illness is a disorder of a family. A special case of this is the sickness of Megalopolis—the person-without-a-family, who is alone and ill with it. A colleague who lives and works in one of the dark districts of London told me the other day that he is called several times a year because some isolated person without family or friends has died in his room; it may be days or a week or two before another tenant notices that the milk hasn't been collected. What more vivid illustration could there be of the kind of life some city-dwellers lead! Of course, the city attracts the man who wants to lose himself and drown in the anonymity of London.
Reading Dr. Clyne's essay prompted me to ponder why this theme of the doctor's 'way with patients'—the whole complex of his attitudes and moods and responses—has not been written about more than it has, and taught as part of the medical curriculum. Is it that doctors, a society at large, have a blind spot? Are the English uneasy about emotions? Certainly many patients with stress dis- orders much prefer to believe that their illness is of bodily origin, and be given tablets for it, or a course of injections. A patient with tension head- ache once said to me, 'If treating my headache means going over all my sordid story, I'd rather have the headache.' But the resistance to explor- ing the emotional background of illness is by no means always on the side of the patient—though the doctor thinks it is. It may be his own embar- rassment that is the blocking agent. Michael Balint's discussion groups for GPs, where topics of this kind are dealt with frankly and freely, are an educative force of the first importance. I am glad to hear that more and more doctors have applied to join them. Group discussions, of another kind, go on in the GP's waiting room. I am tempted to sit in, as a 'patient, and hear what they really think of us.
It has been the convention that man goes out to work and woman keeps house, but when I see Heather I am prompted to speculate on what decides these roles—convention, or biological necessity, or what? Heather and her husband George have swopped roles. Heather runs a large department store; she strides off in the morning to her office, and I don't doubt she is very efficient indeed and perhaps rather tough with her staff, all in the interests of 'the organisation.' She is competitive to a degree, and the sales target of the business is set higher and higher again. George stays at home, cooks, washes up, shops and does all the housework. His wife ex- pects it to be done well and is pretty critical if she finds any dust. Once the work is done, his time is his own. He reads and writes a little; pays calls; and goes to visit two old ladies who have some obscure connection with his family—he feels obliged to them and thinks they need en- couragement once a week and at Christmas. I once read some of his writing. It was dis- cursive and rather dreamy; it carried you along and, in fact, was extremely readable. I asked him why he didn't do more and perhaps have it published, and he replied ruefully that he was too much occupied with his tasks to give it much thought. The point about this arrangement of roles is that until lately it has worked—that is, both partners accepted the duties they had given themselves, Heather as the wage-earner and George as the housewife. The needs of each seemed to be fulfilled in the job they were doing. But in the last few months George has been to sec me several times—a sore throat, an itchy patch on the arm, some pains in the chest. In the old days I never saw him from one year's end to the other. Is it simply that he is getting older? Or is he, at long last, beginning to rebel?
Ten years ago now, James Halliday published his Psychosocial Medicine: A Study of a Sick Society. In the final chapter he says: The aim of this work is essentially ,practical; it is a contri- bution to social synthesis. . . . Without a "men- tal fight" these matters cannot be grasped, and the sword that might have been used will remain sleeping in the hand.' In essence, he meant that our society should take a look at itself and recog- nise the signs of its malaise as they were shown in bodily ailments; then go on from there and do something about it. Ten years—and not very much has happened. But then, the British are slow, cautious, sceptical about new ideas—it is part of their strength. So they don't get carried away and excited to revolution, but go on plod- ding down the middle of the road. The new ideas still come first from Britain, and other people in Holland and Scandinavia and Indonesia notice them, but most of our countrymen don't. Where they don't know their way about in medicine they rely on 'common sense'—as though a surgeon should say : 'Well, I haven't actually learned any
surgery, but take your appendix out by the light of common sense.' Of course, the patient survives. The human organism is remarkably robust—see how it survives the well-intentioned remedies and the thousands of gallons of 'tonic' that are fed into it every day.
MILES HOWARD
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