www.psychspace.com心理学空间网The possibilities of patient-centered medicine*
ENID BALINT, B.Sc.
London
Case work consultant, Tavistock Institute of Human Relations, London; honorary secretary, TrainingCommittee, British Psycho-analytical Society
IN his paper, The Structure of the Training cum Research Seminar and its Implicationfor Medicine, Michael Balint spoke about two classes of pathological conditions:Class I comprises conditions in which a localizable 'illness' can be found. In this classscientific examinations can identify a fault either in the body or in one of the partfunctions in the body. In this way of thinking, the prime aim is to find a localizablefault, diagnose it as an illness and then treat it. This is what we call 'illness-orientatedmedicine.'
In contrast, there is another way of medical thinking which we call 'patient-centredmedicine'. Here, in addition to trying to discover a localizable illness or illnesses, thedoctor also has to examine the whole person in order to form what we call an 'overalldiagnosis'. This should include everything that the doctor knows and understandsabout his patient; the patient, in fact, has to be understood as a unique human-being.The illness which can be described in terms of a 'traditional diagnosis' is either anincident like a broken leg, or a part like accident proneness which makes better senseif understood in terms of the whole.
The question which has recently been occupying our minds is: How does a practisingdoctor avoid a split in himself? How can he avoid being a general practitioner to someof his patients and a competent psychotherapist to others? Or, expressed in our newterminology: How can he avoid practising 'illness-orientated medicine' with some patientsand 'patient-orientated medicine' with others.
Before proceeding it is necessary to state the problem in a slightly different way:What was our aim when, in 1950, we started advertising in the medical press in Londonthat we proposed to hold seminars on the psychological problems in general practice?Did we, in fact, have in mind to teach our doctors to be minor psychotherapists? Didwe aim in establishing this sort of split?
If this were so, why are we so worried about it now, because clearly if this had beenour aim, we could not have expected our doctors to remain whole doctors with oneprofessional activity as they were bound, it would seem, to do 'psychotherapy' withsome patients and 'general practice' with others. Leaving on one side their patients,requirements, the size of their practices alone would not permit them to do minorpsychotherapy with all their patients. Furthermore, if they wished to become psychotherapists they could take the necessary training and leave general practice altogether.
No, there was never any doubt in our minds that the aim of the seminars was to studythe emotional problems found in general practice in the hope that if it were found to benecessary the general practitioner's whole medical approach might be changed; whichmeans that new skills would have to be evolved.
In the later 1950's we thought that we had made some progress, but nevertheless,we began to be anxious about the problem of the split doctor. Our doctors told usthat although they had not altered their way of treating all their patients their wholework had nevertheless changed since they joined our seminars. They could not tell ushow, but they felt themselves to be different kinds of doctors, even different kinds ofpeople since they started work with us. They insisted, nevertheless, that their ordinary'surgeries', i.e. the time they spent in their consulting rooms, were much as they hadbeen before they started; and we found this puzzling.
We had already tried several times to discover how the doctors decided to chooseone patient for psychotherapy rather than another. No answer could be found. Thedoctors realized that their choice was often irrational. That many people who neededinvestigation did not get it and that the most needy were not always chosen for specialattention. Why was this?
When, therefore, in 1962, I was asked to lead a group of experienced generalpractitioners at the Tavistock Clinic I brought the subject up for discussion. This waswith a group of doctors who had already had some experience in the training schemeand were ready to undertake some kind of research. Quite early in our work we decidedto study randomly selected patients in contrast to our usual practice of studying onlythose patients whom the doctors selected specially for discussion.
During this study we made various discoveries.*
Here is the gist of what we found:
First, it seems as if our doctors felt compelled to identify with two professionswhen they joined our seminars; the profession of the general practitioner and theprofession of the psychiatrist and psycho-analyst. All the participants were practisingdoctors but they felt that their work and ours as practising psychiatrists and psychoanalysts was utterly different. They wished us to remember this. It was important tothem to preserve their identity as general practitioners; there were times when theystrongly identified with us, but there were times when they did not wish to do so.Secondly, they saw us, on the one hand, as trying to turn them into psycho-analysts,without the time or the opportunity to do so and on the other forbidding them to practiseanything remotely resembling psycho-analysis. They wanted to show us how exactingour demands were on them and how frustrating and unrealistic. They thought thatwhen we expected them to do more than they did we did not realize how good they wereanyway.
Because of the difficulties inherent in all of this, we felt that we must examine thesituation further and it was for this reason that when this seminar had to be terminatedMichael Balint and I assembled a dozen of our most experienced general practitioners(this time at University College Hospital) and asked them if they would like to co-operatewith us in a research into how much 'patient-orientated medicine' can be done in theordinary run of their practices. This time we did not want to examine randomly chosencases. We wanted the doctors themselves to choose the cases where they felt one brieffive- to ten-minute consultation had started a 'patient-orientated medicine' and we wantedto follow up the cases that the doctors chose over a long period. We called this aresearch into six-minute psychotherapy; but, of course, we did not want to impose astrict time limit on our doctors but to make a distinction between this kind of psychological understanding and therapy and the traditional long interview kind.
Now I want to report something about this research. Many of the attitudes foundin the first research seminar were repeated here. At the beginning it seemed that sometimes our doctors wanted to show us how little they did rather than how much. Inthe usual way, when the same doctors reported on cases the emphasis was on the doctorpatient relationship; and on the way they felt about the patient and why they werefinding difficulties in helping him; whereas, when they reported on their 'six-minutecases', they did so rather in the traditional manner; they based their understanding of thepatient more on traditional medicine (although it might sometimes be from the psychiatricpoint of view). That is, they discussed their findings in terms of dependency or somesimilar cliche and less on the patient's active communication at the time of the interviewand how this could be understood and used for therapy. These were cases where thedoctor did not want to have long interviews and was right in making this decision; butthey could not see that something important for the patient had happened and perhapseven some help had been given to him in the short contact in the consulting room. Otherparticipants in the group might see this but the general practitioner in charge of the caseseldom did. They thought at these times that a formal proper course of psychotherapywith 50-minute interview might be of use, but that nothing else would. They ignoredthe usefulness, which they knew well theoretically, of their unique setting insofar as itgave them the opportunity to see their patients for short times over a number of years.About a year after this research group started work we all realized that we were indifficulties. This became particularly clear when we were listening to the reports onthe follow-ups of our original cases. During the discussion on these cases it appearedthat very good and conscientious and respectable work had been done, but still thetherapeutic results were somewhat disappointing. For instance, although the doctorshad understood very well and worked competently with the patient's illness in terms ofthe present and the past and had seriously tried to identify the area of the patient's lifewhere conflict was most acute and had tried to formulate the iatrogenous and the autogenous illness the work seemed rather flat and undynamic. These ideas, which we hadworked out in our seminars over the years, seemed less useful here than usual: perhapswe did not yet know how to use them in the new setting which we were examiningi.e. in the 'six-minute interview'. Or, were they, in fact, being forced onto the patient?
One doctor said that so far the emphasis had been on what the doctor had tried toget from the patient, rather than on what the patient had tried to get from the doctor;that the doctors seemed to have enjoyed acquiring the skills of detective inspectors.They had learned to spot the patterns of human behaviour underlying the patient'spresenting complaints and ferret out his carefully hidden secrets and fears, but theyhad often failed to shed much light on what the patient tried to get from his doctorwhen the treatment started. This doctor thought that the shift in our work should befrom an overall picture of the patient to the patient's immediate needs. Another doctorthought it might help if we defined different therapeutic aims. The first aim he calledthe 'big bang aim' where the doctor tries to make the overall diagnosis as comprehensiveas possible and then to influence the patient in the major area of his life situation.His success should then be the equivalent of a 'big bang result'. He called the secondaim a 'steady state aim' where the doctor tries to maintain the status quo or restore thebalance of control which the patient appears temporarily to have lost. The third whichhe called the 'little bang aim' was to search modestly into the limited areas of mutualunderstanding between the patient and the doctor. The doctor should try to be on thesame wave-length as the patient and to capitalize such little gains as could be madeeach time so that on subsequent visits work could proceed with a little more done eachtime. This doctor felt that this latter type of aim the 'little bang aim' seemed to be themost promising and realistic for general practitioners during their office hours.
ENID BALINT, B.Sc.
London
Case work consultant, Tavistock Institute of Human Relations, London; honorary secretary, TrainingCommittee, British Psycho-analytical Society
IN his paper, The Structure of the Training cum Research Seminar and its Implicationfor Medicine, Michael Balint spoke about two classes of pathological conditions:Class I comprises conditions in which a localizable 'illness' can be found. In this classscientific examinations can identify a fault either in the body or in one of the partfunctions in the body. In this way of thinking, the prime aim is to find a localizablefault, diagnose it as an illness and then treat it. This is what we call 'illness-orientatedmedicine.'
In contrast, there is another way of medical thinking which we call 'patient-centredmedicine'. Here, in addition to trying to discover a localizable illness or illnesses, thedoctor also has to examine the whole person in order to form what we call an 'overalldiagnosis'. This should include everything that the doctor knows and understandsabout his patient; the patient, in fact, has to be understood as a unique human-being.The illness which can be described in terms of a 'traditional diagnosis' is either anincident like a broken leg, or a part like accident proneness which makes better senseif understood in terms of the whole.
The question which has recently been occupying our minds is: How does a practisingdoctor avoid a split in himself? How can he avoid being a general practitioner to someof his patients and a competent psychotherapist to others? Or, expressed in our newterminology: How can he avoid practising 'illness-orientated medicine' with some patientsand 'patient-orientated medicine' with others.
Before proceeding it is necessary to state the problem in a slightly different way:What was our aim when, in 1950, we started advertising in the medical press in Londonthat we proposed to hold seminars on the psychological problems in general practice?Did we, in fact, have in mind to teach our doctors to be minor psychotherapists? Didwe aim in establishing this sort of split?
If this were so, why are we so worried about it now, because clearly if this had beenour aim, we could not have expected our doctors to remain whole doctors with oneprofessional activity as they were bound, it would seem, to do 'psychotherapy' withsome patients and 'general practice' with others. Leaving on one side their patients,requirements, the size of their practices alone would not permit them to do minorpsychotherapy with all their patients. Furthermore, if they wished to become psychotherapists they could take the necessary training and leave general practice altogether.
No, there was never any doubt in our minds that the aim of the seminars was to studythe emotional problems found in general practice in the hope that if it were found to benecessary the general practitioner's whole medical approach might be changed; whichmeans that new skills would have to be evolved.
In the later 1950's we thought that we had made some progress, but nevertheless,we began to be anxious about the problem of the split doctor. Our doctors told usthat although they had not altered their way of treating all their patients their wholework had nevertheless changed since they joined our seminars. They could not tell ushow, but they felt themselves to be different kinds of doctors, even different kinds ofpeople since they started work with us. They insisted, nevertheless, that their ordinary'surgeries', i.e. the time they spent in their consulting rooms, were much as they hadbeen before they started; and we found this puzzling.
We had already tried several times to discover how the doctors decided to chooseone patient for psychotherapy rather than another. No answer could be found. Thedoctors realized that their choice was often irrational. That many people who neededinvestigation did not get it and that the most needy were not always chosen for specialattention. Why was this?
When, therefore, in 1962, I was asked to lead a group of experienced generalpractitioners at the Tavistock Clinic I brought the subject up for discussion. This waswith a group of doctors who had already had some experience in the training schemeand were ready to undertake some kind of research. Quite early in our work we decidedto study randomly selected patients in contrast to our usual practice of studying onlythose patients whom the doctors selected specially for discussion.
During this study we made various discoveries.*
Here is the gist of what we found:
First, it seems as if our doctors felt compelled to identify with two professionswhen they joined our seminars; the profession of the general practitioner and theprofession of the psychiatrist and psycho-analyst. All the participants were practisingdoctors but they felt that their work and ours as practising psychiatrists and psychoanalysts was utterly different. They wished us to remember this. It was important tothem to preserve their identity as general practitioners; there were times when theystrongly identified with us, but there were times when they did not wish to do so.Secondly, they saw us, on the one hand, as trying to turn them into psycho-analysts,without the time or the opportunity to do so and on the other forbidding them to practiseanything remotely resembling psycho-analysis. They wanted to show us how exactingour demands were on them and how frustrating and unrealistic. They thought thatwhen we expected them to do more than they did we did not realize how good they wereanyway.
Because of the difficulties inherent in all of this, we felt that we must examine thesituation further and it was for this reason that when this seminar had to be terminatedMichael Balint and I assembled a dozen of our most experienced general practitioners(this time at University College Hospital) and asked them if they would like to co-operatewith us in a research into how much 'patient-orientated medicine' can be done in theordinary run of their practices. This time we did not want to examine randomly chosencases. We wanted the doctors themselves to choose the cases where they felt one brieffive- to ten-minute consultation had started a 'patient-orientated medicine' and we wantedto follow up the cases that the doctors chose over a long period. We called this aresearch into six-minute psychotherapy; but, of course, we did not want to impose astrict time limit on our doctors but to make a distinction between this kind of psychological understanding and therapy and the traditional long interview kind.
Now I want to report something about this research. Many of the attitudes foundin the first research seminar were repeated here. At the beginning it seemed that sometimes our doctors wanted to show us how little they did rather than how much. Inthe usual way, when the same doctors reported on cases the emphasis was on the doctorpatient relationship; and on the way they felt about the patient and why they werefinding difficulties in helping him; whereas, when they reported on their 'six-minutecases', they did so rather in the traditional manner; they based their understanding of thepatient more on traditional medicine (although it might sometimes be from the psychiatricpoint of view). That is, they discussed their findings in terms of dependency or somesimilar cliche and less on the patient's active communication at the time of the interviewand how this could be understood and used for therapy. These were cases where thedoctor did not want to have long interviews and was right in making this decision; butthey could not see that something important for the patient had happened and perhapseven some help had been given to him in the short contact in the consulting room. Otherparticipants in the group might see this but the general practitioner in charge of the caseseldom did. They thought at these times that a formal proper course of psychotherapywith 50-minute interview might be of use, but that nothing else would. They ignoredthe usefulness, which they knew well theoretically, of their unique setting insofar as itgave them the opportunity to see their patients for short times over a number of years.About a year after this research group started work we all realized that we were indifficulties. This became particularly clear when we were listening to the reports onthe follow-ups of our original cases. During the discussion on these cases it appearedthat very good and conscientious and respectable work had been done, but still thetherapeutic results were somewhat disappointing. For instance, although the doctorshad understood very well and worked competently with the patient's illness in terms ofthe present and the past and had seriously tried to identify the area of the patient's lifewhere conflict was most acute and had tried to formulate the iatrogenous and the autogenous illness the work seemed rather flat and undynamic. These ideas, which we hadworked out in our seminars over the years, seemed less useful here than usual: perhapswe did not yet know how to use them in the new setting which we were examiningi.e. in the 'six-minute interview'. Or, were they, in fact, being forced onto the patient?
One doctor said that so far the emphasis had been on what the doctor had tried toget from the patient, rather than on what the patient had tried to get from the doctor;that the doctors seemed to have enjoyed acquiring the skills of detective inspectors.They had learned to spot the patterns of human behaviour underlying the patient'spresenting complaints and ferret out his carefully hidden secrets and fears, but theyhad often failed to shed much light on what the patient tried to get from his doctorwhen the treatment started. This doctor thought that the shift in our work should befrom an overall picture of the patient to the patient's immediate needs. Another doctorthought it might help if we defined different therapeutic aims. The first aim he calledthe 'big bang aim' where the doctor tries to make the overall diagnosis as comprehensiveas possible and then to influence the patient in the major area of his life situation.His success should then be the equivalent of a 'big bang result'. He called the secondaim a 'steady state aim' where the doctor tries to maintain the status quo or restore thebalance of control which the patient appears temporarily to have lost. The third whichhe called the 'little bang aim' was to search modestly into the limited areas of mutualunderstanding between the patient and the doctor. The doctor should try to be on thesame wave-length as the patient and to capitalize such little gains as could be madeeach time so that on subsequent visits work could proceed with a little more done eachtime. This doctor felt that this latter type of aim the 'little bang aim' seemed to be themost promising and realistic for general practitioners during their office hours.