Tuesday, June 5, 2012

One Thing I Learned in Medical Training

     One day early in my residency the Residency Director, Dr. Cullen, announced that we would have a Balint Group.  It would meet every week, or every month, depending on the needs of the residents.  Other doctors on staff at the hospital could participate. It would be facilitated by a psychiatrist and a psychologist, both of whom I came to love. They saved me from bewitchment by the scientific method and from the megalithic power that technology and pharmacology were exerting on the structure of medical delivery systems.
     Balint Groups are based on a research project directed by Michael Balint, a physician who in the 1950's posited the theory that the character and interpersonal skills of the doctor have everything to do with whether patients respond to therapy or not.  He was probably influenced by the growing interest in psychotherapeutic theories about personality, transference, and the curious nature of human interactions, ideas whose progenitors--Freud, Jung, Adler--were gaining prominence.
     There were six residents in each of the three years of Family Practice residency training, so there could have been as many as eighteen of us participating, but I don't recall ever seeing more than five or six residents at a time in the Balint Group meetings.  We were all living in such an exhausted state, on-call every few nights, being required to learn life-or-death procedures such as placement of central lines or cardiac resuscitation in the moments when patients were in extremis, and trying to be real people for the small children in our incipient families, that it was only natural to want to absent ourselves from optional activities.
      Participants would sit around a conference table and volunteer "cases," that is, patients whom we were treating with difficulty, patients who made us angry or who weren't getting better despite standard treatment and in defiance, we thought, of the most heroic efforts on our part to cure their medical conditions. Then we would explore the problems the physician-resident might be bringing to the patient encounter, invisible problems except for the way in which they were made manifest in the patient's incapacity or "refusal" to get well.  This was a real turn-around for us.  After following guidelines for appropriate treatment, after learning all the latest medications and methods, and after counseling patients with utmost sensitivity, now we were made to feel, in these meetings, as though our own personalities might carry a "defect" that made the patient fail therapy.  That defect might be invisible to the doctor, who was apt to label the patient "non-compliant," but it wasn't invisible to the group.  We spoke frankly to one another.  "Do you hate this patient?"  "Does this patient remind you of your mother?"  "Might you want the patient to fail therapy so you can experience a familiar frustration that confirms your life-view?"
     Michael Balint's book, The Doctor, His Patient, and the Illness, was not required reading nor was it even mentioned, but I sought it out and read it like a bible.  It contained transcripts of Balint meetings at the Tavistock Clinic from the 1950's.  How bizarre, I thought, as I read through the problem-cases and treatments.  The fourteen doctors who met with a psychiatrist to talk about patients who wouldn't get well used diagnoses and treatments that seemed strange, even ridiculous to my ears.  For example, from the transcripts: "Catarrhal cold.  Neurophosphates administered.  Liver extract injections for psoriasis--producing a complete cure!  Neurosis.  Mourning--A tonic administered. A reassuring pep talk.  Homeopathic remedies for bowel dysfunction or sore throat.  Liquid paraffin for making bowels work.  Burn, mucous membrane--painted and tonic given.  Run down. T.Ferr.Co. and K Br.N.V. given."
     Some of the treatments would be considered malpractice if prescribed today.  Yet patients had miraculous cures.  Michael Balint's conclusions were not new in the history of medicine, but bore repeating, at least to our generation of doctors-in-training:  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. 
     When the doctor-patient relationship is strained by problems with insurance company coverage, requirements to document in writing every single thing that "happens" in the exam room and the reason for every test and treatment given in language an eighth grader could understand (since coding specialists employed by insurance companies are instructed to find discrepancies that will justify non-payment for services), or by the necessity to translate into ICD-9 and CPT-codes the substance of the medical encounter, or by suspicion of the medical profession in general, it is unlikely that the physician will be able to effect a cure.
     It happens not so infrequently that the relationship between the patient and his doctor is strained, unhappy, or even unpleasant.  It is in these cases that the drug "doctor" does not work as it is intended to do.  These situations are quite often truly tragic; the patient is in real need of help, the doctor honestly tries his hardest--and still, despite sincere efforts on both sides, things tend obstinately to go wrong.
     I would say that there are now such enormous outer circumstances affecting the doctor-patient relationship in a destructive way that the "cure" of the patient has become more an anomaly.  Very often the interaction between the two is adversarial, in part because of demoralizing constraints on the practice of medicine by insurance carriers and governmental agencies, negative media coverage of the medical profession, frivolous litigation against doctors for the purposes of winning large monetary awards, and the nearly impossible task of running a business (made oppressive by overzealous regulatory agencies) while being the business--an onus for the solo doctor.  When we add to these challenges the impact of the uninspected psychological state of the physician, the situation for patients becomes fairly hopeless.
     When patients cannot be "cured" by their usual physician they often doctor-hop to urgent care clinics, emergency rooms, or a multitude of alternative providers for "second opinions" in the hope of re-establishing the relationship which at some level they know is the healing element necessary for their recovery. In this way the cost to society for not connecting with patients becomes enormous.

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