INT’L J. PSYCHIATRY I N MEDICINE, Vol. 6 (112). 1975
THE DOCTOR-PATIENT RELATIONSHIP IN THE PRACTICE OF MEDICINE Wolfram Schuffel, M.D.’ University of Ulm, West Germany ABSTRACT-The patientdoctor relationship is based on the principles of interaction, collecting data and integration of both interaction and data into an overall diagnosis/therapy. Patients with functional abdominal disorders are seen as representatives of today’s general patients and a study of their management in present medical practice is reported, as revealed through literature. The literature reveals an almost complete neglect of interactional and integrational principles. This holds true even for psychosomatically oriented literature, which offers some crude clinical guidelines at best. Thus the primary physician gets little support from psychosomatic medicine in understanding the full meaning of the doctorpatient relationship. The clinical implications of the relationship are demonstrated through a short case history and implications for future training are described which are based on the primary physician’s actual working experiences.
THE PROBLEM The doctor-patient relationship has become the object of intensive psychosomatically oriented studies which prove its diagnostic and therapeutic importance [ 11 . Balint’s attempts in the field of general medicine have focused on this central issue of medical practice from the interactional point of view [2]. In Balint’s opinion every doctor-patient relationship is seen as an interaction between two partners-each of them having definite expectations concerning the individual encounter; this is the interactional principle of any doctor-patient relationship. Engel and his co-workers [3j point out the necessity of seeing the patient’s illness within the total life context. The resulting evaluation has to be integrated into the comprehensive care of the patient as provided by.the facilities of today’s highly specialized medicine. This point of view is based on the integrational principle inherent in any doctor-patient relationship. Besides the collection of data, both interaction and integration are thought to be the main principles of the doctor-patient relationship. Department of Psychosomatic Medicine, Center of Medicine and Pediatrics, University of Ulm, 79 Ulm, West Germany.
183 0 1976.Baywood Publishing Co., Inc.
doi: 10.2190/HMFL-KWMN-9XBE-WADG http://baywood.com
184
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Wolfram Schuffel
Interactional and integrational principles are found closely interconnected in any psychosomatically oriented work, and corresponding psychosomatic activities are now world-wide. Balint was a proponent of this underlying approach in Britain, and so are Engel in the United States, Groen in the Netherlands, and von Uexkiill in Germany. Yet critical opinions as to the feasibility and practicability of the psychosomatic approach are expressed. It is argued that forty years of psychosomatic medicine, consulting service and liaison service have left medicine untouched [4]. These arguments have to be taken seriously, as they both in fact reflect present reality and are discouraging to those working in what seems to be a no-man’s-land. Psychosomatic medicine is far from being an accepted clinical approach [5], not to mention the approach in medicine. AIM OF THE STUDY The aim of this study is to examine the reasons leading to the omission of a deliberate application of principles of the doctor-patient relationship in present practice of medicine. As pointed out, interaction and integration are seen as the two main principles besides collecting data which decide the quality of any patient-doctor relationship. The reasons leading to a partial or total omission of those two principles will be discussed on the following levels: 1) the circumstances of the doctor-patient relationship within present health care delivery; 2 ) the clinical applicability of our knowledge of the doctor-patient relationship; 3) relation between medical practice and psychosomatic knowledge; 4) consequences as outlined by the application of the two main principles to an individual doctor-patient relationship; and 5) future ways of realization of a psychosomatic approach in the practice of medicine. The study is designed as a kind of “single-case-study”-i.e., problems inherent in the management of patients with functional abdominal disorders (FAD) will illustrate those problems which are generally found in psychosomatically oriented medical practice. The group of FAD-patients is chosen because the existence of psychosocial problems in those patients has been proven beyond any doubt. MATERIAL The literature review is mainly based on approximately 400 references related to the problem of FAD-patients in medical practice, many of which were obtained in a MEDLARS search covering the period from January 1964 to November 1973. A minor number of references were also obtained through the Index of Chicago Institute of Psychoanalysis. Also included are observations of patients suffering from FAD whom the author treated as a primary physician and/or as a dynamically oriented psychotherapist.
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I . Circumstances of the Doctor-Patient Relationship within Present Health Care Delivery The word “functional” in the above meaning of FAD is not even registered in the indices of three standard medical books on gastroenterology and internal medicine respectively [6-81. This could not be rectified despite the active collaboration of proponents of the comprehensive approach. In the 1900-page Cecil-Loeb textbook [7] the paragraph on “irritable colon” (which is almost identical with FAD in this textbook) covers 2 pages. On the other hand the editors think that the textbook “has served as a standard reference work throughout the professional lives of most physicians now in active practice.” And they express their hope that “this new work will once again serve the needs of students of all ages” (p. vi). It is evident that many generations of students find very little help from textbooks like these standard ones when they are confronted in practice with the following facts: While about 10 per cent of the general population exhibit FAD, only 4 per cent of them do go to the doctor. Why this is so is not known at present. The general practitioner sees two or three of these patients per day [9] . Patients with FAD represent 40-60 per cent of the gastroenterologist’s patients [lo-121 and 90 per cent of all school children with abdominal pain visiting the pediatrician [ 131 . It was suggested almost 100 years ago that psychosocial factors were of etiological relevance and that the management of those patients may turn out to be a difficult challenge for the physician [14]. Both the psychological relevance of psychosocial events and the difficulties in management were demonstrated in a random sample investigated 35 years ago [15]. This was confirmed in recent years [16-181. Although the interaction itself is not described in standard medical texts, it is seen that the patients continue to be a major “challenge” to the physician [ 1 11 . Unfortunately the above knowledge is not integrated into diagnosis and treatment of those patients. Psychosocial problems are often not acknowledged [19-211, seemingly “nonspecific abdominal pain” is found in 50 per cent of all acute abdominal pain [22] and often surgical intervention takes place [23]. The prognosis for somatic complaints and psychosocial rehabilitation remains extremely poor [ l l , 17, 191. Patients with FAD will be treated “sympathetically,” and with cellulose [24], as they were treated forty years ago [25] ? On other occasions the physician can’t hide his annoyance and the patients are dismissed as “crocks” [26] or as “faule EieY3 in German hospitals. Interestingly peptic ulcer patients are their “organic” counterparts: These patients are treated as they were treated 50 years ago, when no psychosomatic medicine and no biogastrone but only antacids were available [ 2 7 ] . “Bad eggs.”
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Thus current literature reflects the vague feeling found in modern medical practice that these patients need understanding and sympathy. This may be seen as a reference to interactional aspects within the doctor/FAD-patient situation. However there are no signs of an integration of interactional aspects into a comprehensive approach.
2. Clinical Applicability of Psychosomatic Knowledge to the Doctor-Patient Relationship: f i e Doctor Is Left Out The prevailing modes of interaction within the doctor-patient relationship will be formed by the prevailing attitudes of the FAD-patients and by those reactions they induce in their doctors. The patients with FAD are usually described as aggressive-resentful [15, 281 , anxious [20, 291, depressive [16], over-conscientious [ 171 ; even gross social deviations may be found as recently described [ 181 . Fifty per cent regard their marriages as failures and disappointments; vocational adjustment is poor; insight is poor [30] . Being engaged in the care of those patients who are admitted to our hospital the author is usually struck by the “somatic” tone of their communication. They hardly speak of psychosocial events unless the events are closely connected with their complaints and their management. They resemble “alexithymic” patients who are chronically unable to express their feelings [3 11 . Experienced clinicians emphasize the role of the physician’s personal attitude [19, 20, 321. Apart from anecdotal communications, however, there are no reports on the physician’s reaction to this particular group of patients and to their complaints. It is not difficult to imagine the physician’s reaction to a chronically anxious, aggressive-resentful or even sociopathic patient. Either the physician tries to compensate for his own aggression and resentments by being “kind and wise” [ 191 or reassuring [33] , or his own aggressions break through. It is evident that the resulting doctor-patient relationship is endangered and that all integrational efforts are greatly hampered. The treatment situation is marked by the patient’s “somatic” complaints and his resistance towards any question which is concerned with personal feelings. On the other hand all integrational activities are marked by the physician’s uncertainty as a diagnostician. Usually he knows from the patient’s clinical picture and from the beginning of the clinical investigation that there are many psychosocial problems and no structural changes, yet he is afraid at the same time of being reproached for professional negligence if he doesn’t make use of the whole medical diagnostic apparatus. These integrational difficulties are discussed most aptly by the pediatrician Apley [ 131 , who states in the case of child patients: Recurrent abdominal pain is usually part of a pattern of reaction to emotional stress with the child’s pattern of reaction reflecting a family pattern. The differential diagnosis of illness mechanisms has to be based on probability and clinical feature. Common but unjustifiable diagnoses have to be excluded as “unacceptable causes” of FAD (like worms, chronic appendicitis, non-specific mesenteric lymphadenitis,
The Doctor-Patient Relationship / 187 food sensitivity, epilepsy). The physician is warned against resorting to unproven or even wrong diagnostic/therapeutic cliches, against “bulldozing” as a diagnostician and against over-estimation of drug treatment which is at best superficial.
Apley’s clinical considerations integrate the quality of the individual doctorpatient relationship. The doctor has to assess his own feelings and tries to convey them in an understandable and nonhurting way to the patient [34] in order to achieve diagnostic/therapeutic progress. If the ultimate goal of integrational efforts is management through doctorpatient relationship we have to look for descriptions of both the patient’s and the doctor’s behavior. In doing so we see the literature of approximately 400 references shrink down to two references [ 13,321 .Unfortunately even in those two references no detailed advice on the management of the physician’s own behavior is given either. In other words, the whole literature on FAD-patientswhether traditionally clinical or specifically psychosomatic-provides no clearcut description of the comprehensive approach to this kind of patient. 3. Relation between Medical Practice and General Psychosomatic Knowledge: The Doctor’s Private Code We have learned that current psychosomatic knowledge on the management of FAD-patients offers little help of practical value. At best the primary physician is offered general guidelines. It is up to the physician to apply them individually, which of course presents tremendous difficulties, and its realization will depend on the physician’s private resources. In a recent study on the management of forty-two hospital patients with functional disorders five different qualities of a clinical approach were found [22]. They were based on the physician’s varying willingness to accept and to integrate psychosocial factors into the care of the patient. In an attempt to explain the results of this study two main factors seem relevant: 1) there is a lack of basic knowledge (not available, ignored, or both) enabling an integration of the data elicited into the whole-person of the patient; and 2) the physicians exhibit different personal capacities for defining and coping with their own feelings. It is understandable that these two factors greatly influence the clinical quality of the care of the patient. Consequently each physician develops a style of his own which is based on personal likes and dislikes but is hardly affected by a deliberate checking of factors which influence the doctor-patient relationship as induced by the doctor. In conclusion we may say that psychosomatic medicine and general medicine offer merely crude guidelines on the interactional and integrational level of patient care. Even the guidelines are not easily available and hardly applicable for the untrained physician in the usual clinical setting. Each physician develops a‘ private professional code when treating these patients. This code is usually untouched by psychosomatic medicine and it is located on a broad emotional
188 / Wolfram Schiiffel spectrum between FAD-patient = crock and FAD-patient = “poor guy” in need of sympathy.
4. Consequences Outlined in the Application of Interactional and Integrational Principles in an Individual Doctor-Patient Relationship; A Case Study Modes of Referral and Visits to the Doctor: The 54-year-old Frau A. K. had been referred for a psychosomatic consultation while still waiting to be examined in the outpatient department. I was asked to explore the reasons for her depression, which was in the referring doctor’s opinion related to her bodily complaints. Including the initial talk, there were four meetings between doctor and patient each, lasting about thirty minutes over a period of two and one-half months. Interaction: Establishing a Relationship The patient looked slightly older than her actual age but otherwise she seemed to be in good physical condition. She was neatly dressed and she had obviously just come from the hairdresser’s. Her gestures were controlled, but she seemed lonely. Her physician (the author) felt like a son sitting opposite a grieving mother. Nevertheless, he refrained from consoling her and told her about his own feeling. After ten minutes filled with bodily complaints, she reported on her son and her mother and she wept. Interaction: The Patient’s General Relationships Twelve years ago she, her husband (now 74), and her son (now 23), had gone to the States; five years ago they had come back because of the patient’s aging and lonely mother. The husband, who then had cancer of the prostrate, had grudgingly given in to his wife’s wishes for their return. A few months after the return the mother died and the son went back to the States. Neither patient nor husband, who were East German refugees, had relatives. Collecting Data: Illness History She complained of epigastric pain, heart bum, belching, and a bitter taste on her tongue from which she had suffered for about four years. She had visited altogether five doctors, had been admitted to a district hospital; a herniatomia had been suggested but not performed. Beginning Integration: Life History and Complaints Since the age of 30 she had regularly observed some gastrointestinal disturbances similar to the above ones. Professional help had not been necessary, however. There had been no major diseases in her life. The present disturbances started to become intolerable about four years ago when she came back from Detroit to a small Swabian town.
Evaluation Overall diagnosis. The contents o f the first meeting with the patient may be seen in the light of the two basic principles of interaction and integration besides the principle of collecting data. The physician’s task consists of integrating both
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data and characteristics of the relationship into an overall diagnosis/therapy. Establishing the relationship with the patient, the physician tried to register his feelings as clearly as possible; these were related to her loneliness, sadness and deep seated but hardly recognizable resentment. The physician felt that they were related to her husband, son and doctor (including himself). Integrating feelings and data into a picture of the whole person, the following overall diagnosis appeared to be likely although the results of the physical and laboratory examinations were not available at that time: A 54-year-old female patient whose 73-year-old husband has cancer of the prostrate and who feels deserted by her only child a son as a result of her own behavior. Digestive complaints which had been present almost all her life were aggravated after a series of threatening life events five years ago; they seemed to be cqused by functional disturbances of the upper gastrointestinal tract. She expected the doctors to diagnose those disturbances as somatically induced disorders.
Implications for therapy (overall therapy). Beginning with the first meeting, attempts were made to define the patient’s prevailing mood and to encourage her to verbalize her feelings and to relate them to the most important persons and events of her life. Attempts were made to let the patient know what the doctor’s sensations and feelings were when he listened to her. A characteristic passage of the first meeting was: “I cried a lot when the boy left and mother died. All right, he was 18 and he had grown up in that country. He does look after himself but nevertheless you do feel worried” [patient wept] . In the second meeting persons and events and somatic feeling states were brought together. The patient started to ventilate the impact of the life events: “Well, when the boy had left just after our return from the States, and when mother had suddenly died . . . it was then that I got all the stomach trouble . . . I even woke up at night, I was sweating and I felt panicky.” By the third meeting the doctor-patient relationship had become stable; the patient compared doctor and (beloved) son positively and was thus able to express her resentment; somatic complaints were no longer mentioned: “He [the husband] always blames me for being here [in Germany] ; h e tells me that I couldn’t help my mother anyway . . . ; h e doesn’t want to talk about the future nor about his illness. . . . He doesn’t understand me nor did he understand my son who used to come to me to talk things over . . . Talking to you is getting easier.” In the fourth meeting the ventilation of affects was precluded. For the first time within the last four years the patient was planning ahead, and the threat of chronic invalidity had been counteracted. “He [the husband] is old and he is not in good health; well he is ill. . . . I don’t know what will happen when he dies. My son will not come back, that’s what I am sure about. . . . I still have an exchange with an old lady in Detroit who is 70. She really is happy with her job as a pink lady in one of the Detroit hospitals.. . . [She explained
190 I Wolfram Schiiffel in detail how those voluntary visitors benefited from the visits at least as much as the patients themselves.] That’s what keeps her fit. Perhaps you are right and I should look for people to talk to.”
Follow up. Meanwhile the patient has started planning for the future. She thinks of becoming a pink lady in the little Swabian town herself. Her symptoms have vanished. When they reappear occasionally, she treats them with antacids and she is not worried by them as she used to be. Conclusions from Case History Establishing a relationship between patient and doctor includes 1) interaction between two partners, 2) collecting data, and 3) integrating data and main lines of interaction into the overall diagnosis. Characteristics of an overall therapy were followed up in all four encounters. Successive therapeutic steps were: the patient’s experiencing of affects, her relating of affects to persons/events and consequently to bodily sensations, her ventilation of interpersonal relationships including the doctor-patient relationship, and her planning of a concrete life period. At all stages I tried to communicate my perception of her feeling state to the patient. Additionally she was given medication ad libitum (antacids). In this case a diagnostic/therapeutic breakthrough was achieved through a deliberate application of the doctor-patient relationship and when: 1) the main affective characteristics of the interaction were identified and developed; and 2) characteristics of interaction were related to illness mechanisms and integrated into a whole person approach. This kind of breakthrough was not achieved in former visits to different doctors. Up to then the doctor-patient relationship was not applied as diagnostic/therapeutic tool. The reason for this is disregard of existent knowledge in medicine, lack of personal training and of adequate psychosomatic knowledge, and insufficient exchange of knowledge from the field of psychosomatic medicine. 5. Future Possibilities for the Introduction of Interactional
and Integrational Principles into Practice of Medicine Patients with FAD as Representatives of Today’s General Patients. In the above mentioned study on the management of hospital patients with functional disorders [22], no difference was revealed in the diagnostic and therapeutic procedures applied to patients with different functional disorders; similar observations have been reported [21]. Thus it can be accepted that the doctor’s attitude towards FAD-patients is representational of the physician’s general attitude towards all patients with functional disturbances. Moreover, those patients demonstrate no structural lesions nor gross physiological disorders when
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compared with the patient with coronary infarction, peptic ulcer or hypertension, thyrotoxicosis, and so forth. The aim of present medical practice is directed at diagnosis and treatment of structural lesions and physiological disorders. Thus the physician is trained to look for them and to accept them finally as the sole reasons for his patient’s breakdown. Psychosocial factors are regarded to be negligible in those cases. In my opinion one can apply the rule of thumb: if the doctor doesn’t see psychosocial aspects in “functional” patients he won’t see any in “organic” patients. TECHNIQUES FOR INTRODUCING INTERACTIONAL AND INTEGRATIONAL PRINCIPLES INTO PRACTICE OF MEDICINE Six years ago Weed proposed the introduction of problem-oriented patient records [35], and his methods have been practiced widely. Although Weed’s ideas represent a major step towards practice of comprehensive medicine by, as he says, “guiding and teaching” the physicians, the discussion on problemoriented records omits mention of principles of the doctor-patient relationship which is basic to any treatment situation. Resulting problems can be identified only if the main elements of the individual patient-doctor relationship are seen and integrated into the record. This relationship itself is a condensed replica of those situations in the patient’s life history when he needed help. The present relationship between the partners is characterized by the complementarity between help-seeker and help-provider. This is laid down in the rules of a contract between patient and doctor as recently pointed out by Engel [36]. The patterns of the complementarity have to be examined and thus interaction will be experienced by the individual physician. In order to achieve this goal of working on an affective level, adequate working styles have been described by Balint and co-workers [37]. Psychosomatic medicine has to establish and to systematize our knowledge of the pathogenetic and therapeutic effect of psychosocial factors which are of relevance to the patient-doctor relationship. A promising avenue in this field appears to be the work on the combined effect of life change and social assets on the outcome of illness [38,39]. The least studied area of integrating the behavioral aspect into practice of medicine still remains. This task has to be accomplished if psychosomatic medicine is to be established as a clinical approach. We are now at a stage which allows a clearer delineation of the setting, thus enabling the physician to get sufficient support for achieving a comprehensive approach: Only the physician who is in primary care of the patient will experience the implications of These considerations are based on a paper “Future Training in Clinical Psychosomatic Medicine” read at the constitution assembly of the West German Association of Clinical Psychosomatic Medicine, held in Ulm, March 2 , 1974.
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interactional and integrational principles of the doctor-patient relationship. Interactional and integrational implications have to be elaborated by techniques which are demonstrated by experienced clinicians [40] applying techniques as devised within modern liaison work [3, 411 . Those clinicians are the leaders of both interaction- and integration-oriented working sessions. This kind of training is based on affective learning and on empathy which can be taught. It clearly differs, however, from traditional psychoanalytic training and training in behavior modification. This training takes place within the physician’s actual working field as provided in private practice, hospital wards and outpatient departments. If psychosomatic medicine is regarded as a clinical approach as it is in this study, it has to stick to its roots-the patientdoctor relationship.
REFERENCES 1. Crisp AH: Therapeutic aspects of the doctor/patient relationship: attempted measurement of some factors. Psychother Psychosom 18:12-33,1970 2. Ealint M: The Doctor, His Patient and the Illness (2nd ed). London, Pitman Medical 1964 3. Morgan WL, Engel GL: The Clinical Approach to the Patient. Philadelphia, Saunders Company, 1969 4. McKegney FP: Consultation-liaison teaching of psychsomatic medicine: opportunities and obstacles. J Nerv Ment Dis 154:198-205,1972 5 . Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: 111. Theoretical Issues. Psychosom Med 30:395422, 1968 6. Paulson M: Gastroenterologic Medicine. Philadelphia, Lea & Febiger, 1969 7. Beeson PB, McDermott W: Cecil-Loeb Textbook of Medicine (13th ed). Philadelphia, W.B. Saunders Company, 1971 8. Sleisenger MH, Fordtran JS: Gastrointestinal Disease. Philadelphia, W.B. Saunders Company, 1973 9. Wadsworth MEJ. Butterfield WJH. Blaney R: Health and Sickness: The Choice of Treatment. London, Tavistock Publications, 197 1 10. Fahrlander H: Functional distorders in the gastro-intestingal tract. Dtsch Med J 23~162-67,1972 11. Kirsner JB: Clinical challenge of functional gastrointestinal disorders. Postgrad Med 39~565-75.1966 12. Sklar M: Functional gastrointestinal disease in the aged. Amer J Gastroent 53:570-75, 1970 13. Apley J: The child with recurrent abdominal pain. Pediat Cli; N Amer 14:64-72, 1967 14. Da Costa JM: Membranous enteritis. Amer J Med Sci 62:321-35, 1871 15. White BV, Cobb S, Jones CM: Mucous Colitis: A Psychological Medical Study of 60 Cases. Psychosom Med Monograph I, 1939 16. Chaudhary NA, Truelove SC: The irritable colon syndrome: a study of the clinical features, predisposing causes, and prognosis in 130 cases. Quart J Med 31:307-22, 1962 17. Hill OW, Blendis L: Physical and psychological evaluation of “non-organic” abdominal pain. Gut 8:221-29,1967 18. Cummings JH, Sladen GE, James OFW, et al: Laxative-induced diarrhoea: a continuing clinical problem. Brit Med J 1 5 3 9 4 1 , 1 9 7 4 19. Waller SL, Misiewicz JJ: Prognosis in the irritable-bowel syndrome. Lancet II:753-56, 1969 20. Engelhardt K, Strothmann G: Clinical aspects of the psychovegetative syndrome. Med Klin 66~1377-85,1971 21. Schuffel W: The need for an integrational attitude in medicine: how the phsyician cares for patients with functional disorders. Psycho-Ecology, No. 1 (in press)
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22. De Dombal FT, Leaper DJ, Horrocks JC, et al: Human and computer-aided diagnosis of abdominal pain: further report with emphasis on performance of clinicians. Brit Med J 1~376-80,1974 23. Devor D, Knauft RD: Exploratory laparotomy for abdominal pain of unknown etiology: diagnosis, management, and follow-up of 40 cases. Arch Surg (Chicago) 96:836-39,1968 24. Martini GA: Personal communication, Wiesbaden, 1974 25. Jordan SM, Kiefer ED: The irritable colon. JAMA 93:592-95, 1929 26. Lipsitt DR: Medical and psychological characteristics of “crocks.” Int J Psychiat in Med 1~15-25,1970 27. Haemmerli U: Personal communitcation. Weisbaden, 1974 28. Harris ID: Relation of resentment and anger to functional gastric complaints, Psychosom Med 8:211-15,1946 29. Halsted JA, Schwarz R, Rosen SR, et al: Correlated gastroscopic and psychiatric studies of soldiers with chronic non-ulcerative dyspepsia. Gastroenterology 7:177-90, 1946 30. Klein HR: A personality study of one hundred unselected patients attending a gastro-intestinal clinic. Amer J Psychiat 104:433-39,1948 31. Sifneos PE: The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom 22:255-62, 1973 32. Moeller HC: Treatment of irritable colon. Mod Treatment 2:988-1002, 1965 33. McKegney FP: Psychosomatic gastrointestinal disturbances: a multifactor, interactional concept. Postgrad Med 47:109-13,1970 34. Clyne MB: The diagnosis, in Six Minutes for the Patient: Interactions in General Practice Consultation. London, Tavistock Publications, 1973 35. Weed LL: Medical records that guide and teach. New Engl J Med 278:593-99; 652-57, 1968 36. Engel GL: Enduring attributes of medicine relevant for the education of the physician. Ann Intern Med 78587-93, 1973 37. Balint M, Balint E, Gosling R, Hildebrand D: A Study of Doctors. London, Tavistock Publications, 1966 38. Rahe RH: Subjects’ recent life changes and their near-future illness susceptibility. Adv Psychosom Med 8:2-19,1972 39. Dudley DL, Holmes TH, Van Arsdel PP, De Araujo G: Quantification of psychosocial variables in intrinsic asthma: relationship to physiological variability. Second Conference of the International College of Psychosomatic Medicine, Amsterdam, 1973 (unpublished) 40. Uexkiill TH Von: Die Aufgaben der psychosomatischen Medizin in der Ausbildung zum Arzt. Verband Schweizer Medizinstudenten, Bern 1-13, 1973 41. Engel GL: Medical education and the psychosomatic approach: a report on the Rochester experience, 1946-1966. J. Psychosom Res 11:77,1967
THE DOCTOR-PATIENT RELATIONSHIP IN THE PRACTICE OF MEDICINE Wolfram Schuffel, M.D.’ University of Ulm, West Germany ABSTRACT-The patientdoctor relationship is based on the principles of interaction, collecting data and integration of both interaction and data into an overall diagnosis/therapy. Patients with functional abdominal disorders are seen as representatives of today’s general patients and a study of their management in present medical practice is reported, as revealed through literature. The literature reveals an almost complete neglect of interactional and integrational principles. This holds true even for psychosomatically oriented literature, which offers some crude clinical guidelines at best. Thus the primary physician gets little support from psychosomatic medicine in understanding the full meaning of the doctorpatient relationship. The clinical implications of the relationship are demonstrated through a short case history and implications for future training are described which are based on the primary physician’s actual working experiences.
THE PROBLEM The doctor-patient relationship has become the object of intensive psychosomatically oriented studies which prove its diagnostic and therapeutic importance [ 11 . Balint’s attempts in the field of general medicine have focused on this central issue of medical practice from the interactional point of view [2]. In Balint’s opinion every doctor-patient relationship is seen as an interaction between two partners-each of them having definite expectations concerning the individual encounter; this is the interactional principle of any doctor-patient relationship. Engel and his co-workers [3j point out the necessity of seeing the patient’s illness within the total life context. The resulting evaluation has to be integrated into the comprehensive care of the patient as provided by.the facilities of today’s highly specialized medicine. This point of view is based on the integrational principle inherent in any doctor-patient relationship. Besides the collection of data, both interaction and integration are thought to be the main principles of the doctor-patient relationship. Department of Psychosomatic Medicine, Center of Medicine and Pediatrics, University of Ulm, 79 Ulm, West Germany.
183 0 1976.Baywood Publishing Co., Inc.
doi: 10.2190/HMFL-KWMN-9XBE-WADG http://baywood.com
184
/
Wolfram Schuffel
Interactional and integrational principles are found closely interconnected in any psychosomatically oriented work, and corresponding psychosomatic activities are now world-wide. Balint was a proponent of this underlying approach in Britain, and so are Engel in the United States, Groen in the Netherlands, and von Uexkiill in Germany. Yet critical opinions as to the feasibility and practicability of the psychosomatic approach are expressed. It is argued that forty years of psychosomatic medicine, consulting service and liaison service have left medicine untouched [4]. These arguments have to be taken seriously, as they both in fact reflect present reality and are discouraging to those working in what seems to be a no-man’s-land. Psychosomatic medicine is far from being an accepted clinical approach [5], not to mention the approach in medicine. AIM OF THE STUDY The aim of this study is to examine the reasons leading to the omission of a deliberate application of principles of the doctor-patient relationship in present practice of medicine. As pointed out, interaction and integration are seen as the two main principles besides collecting data which decide the quality of any patient-doctor relationship. The reasons leading to a partial or total omission of those two principles will be discussed on the following levels: 1) the circumstances of the doctor-patient relationship within present health care delivery; 2 ) the clinical applicability of our knowledge of the doctor-patient relationship; 3) relation between medical practice and psychosomatic knowledge; 4) consequences as outlined by the application of the two main principles to an individual doctor-patient relationship; and 5) future ways of realization of a psychosomatic approach in the practice of medicine. The study is designed as a kind of “single-case-study”-i.e., problems inherent in the management of patients with functional abdominal disorders (FAD) will illustrate those problems which are generally found in psychosomatically oriented medical practice. The group of FAD-patients is chosen because the existence of psychosocial problems in those patients has been proven beyond any doubt. MATERIAL The literature review is mainly based on approximately 400 references related to the problem of FAD-patients in medical practice, many of which were obtained in a MEDLARS search covering the period from January 1964 to November 1973. A minor number of references were also obtained through the Index of Chicago Institute of Psychoanalysis. Also included are observations of patients suffering from FAD whom the author treated as a primary physician and/or as a dynamically oriented psychotherapist.
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I . Circumstances of the Doctor-Patient Relationship within Present Health Care Delivery The word “functional” in the above meaning of FAD is not even registered in the indices of three standard medical books on gastroenterology and internal medicine respectively [6-81. This could not be rectified despite the active collaboration of proponents of the comprehensive approach. In the 1900-page Cecil-Loeb textbook [7] the paragraph on “irritable colon” (which is almost identical with FAD in this textbook) covers 2 pages. On the other hand the editors think that the textbook “has served as a standard reference work throughout the professional lives of most physicians now in active practice.” And they express their hope that “this new work will once again serve the needs of students of all ages” (p. vi). It is evident that many generations of students find very little help from textbooks like these standard ones when they are confronted in practice with the following facts: While about 10 per cent of the general population exhibit FAD, only 4 per cent of them do go to the doctor. Why this is so is not known at present. The general practitioner sees two or three of these patients per day [9] . Patients with FAD represent 40-60 per cent of the gastroenterologist’s patients [lo-121 and 90 per cent of all school children with abdominal pain visiting the pediatrician [ 131 . It was suggested almost 100 years ago that psychosocial factors were of etiological relevance and that the management of those patients may turn out to be a difficult challenge for the physician [14]. Both the psychological relevance of psychosocial events and the difficulties in management were demonstrated in a random sample investigated 35 years ago [15]. This was confirmed in recent years [16-181. Although the interaction itself is not described in standard medical texts, it is seen that the patients continue to be a major “challenge” to the physician [ 1 11 . Unfortunately the above knowledge is not integrated into diagnosis and treatment of those patients. Psychosocial problems are often not acknowledged [19-211, seemingly “nonspecific abdominal pain” is found in 50 per cent of all acute abdominal pain [22] and often surgical intervention takes place [23]. The prognosis for somatic complaints and psychosocial rehabilitation remains extremely poor [ l l , 17, 191. Patients with FAD will be treated “sympathetically,” and with cellulose [24], as they were treated forty years ago [25] ? On other occasions the physician can’t hide his annoyance and the patients are dismissed as “crocks” [26] or as “faule EieY3 in German hospitals. Interestingly peptic ulcer patients are their “organic” counterparts: These patients are treated as they were treated 50 years ago, when no psychosomatic medicine and no biogastrone but only antacids were available [ 2 7 ] . “Bad eggs.”
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Thus current literature reflects the vague feeling found in modern medical practice that these patients need understanding and sympathy. This may be seen as a reference to interactional aspects within the doctor/FAD-patient situation. However there are no signs of an integration of interactional aspects into a comprehensive approach.
2. Clinical Applicability of Psychosomatic Knowledge to the Doctor-Patient Relationship: f i e Doctor Is Left Out The prevailing modes of interaction within the doctor-patient relationship will be formed by the prevailing attitudes of the FAD-patients and by those reactions they induce in their doctors. The patients with FAD are usually described as aggressive-resentful [15, 281 , anxious [20, 291, depressive [16], over-conscientious [ 171 ; even gross social deviations may be found as recently described [ 181 . Fifty per cent regard their marriages as failures and disappointments; vocational adjustment is poor; insight is poor [30] . Being engaged in the care of those patients who are admitted to our hospital the author is usually struck by the “somatic” tone of their communication. They hardly speak of psychosocial events unless the events are closely connected with their complaints and their management. They resemble “alexithymic” patients who are chronically unable to express their feelings [3 11 . Experienced clinicians emphasize the role of the physician’s personal attitude [19, 20, 321. Apart from anecdotal communications, however, there are no reports on the physician’s reaction to this particular group of patients and to their complaints. It is not difficult to imagine the physician’s reaction to a chronically anxious, aggressive-resentful or even sociopathic patient. Either the physician tries to compensate for his own aggression and resentments by being “kind and wise” [ 191 or reassuring [33] , or his own aggressions break through. It is evident that the resulting doctor-patient relationship is endangered and that all integrational efforts are greatly hampered. The treatment situation is marked by the patient’s “somatic” complaints and his resistance towards any question which is concerned with personal feelings. On the other hand all integrational activities are marked by the physician’s uncertainty as a diagnostician. Usually he knows from the patient’s clinical picture and from the beginning of the clinical investigation that there are many psychosocial problems and no structural changes, yet he is afraid at the same time of being reproached for professional negligence if he doesn’t make use of the whole medical diagnostic apparatus. These integrational difficulties are discussed most aptly by the pediatrician Apley [ 131 , who states in the case of child patients: Recurrent abdominal pain is usually part of a pattern of reaction to emotional stress with the child’s pattern of reaction reflecting a family pattern. The differential diagnosis of illness mechanisms has to be based on probability and clinical feature. Common but unjustifiable diagnoses have to be excluded as “unacceptable causes” of FAD (like worms, chronic appendicitis, non-specific mesenteric lymphadenitis,
The Doctor-Patient Relationship / 187 food sensitivity, epilepsy). The physician is warned against resorting to unproven or even wrong diagnostic/therapeutic cliches, against “bulldozing” as a diagnostician and against over-estimation of drug treatment which is at best superficial.
Apley’s clinical considerations integrate the quality of the individual doctorpatient relationship. The doctor has to assess his own feelings and tries to convey them in an understandable and nonhurting way to the patient [34] in order to achieve diagnostic/therapeutic progress. If the ultimate goal of integrational efforts is management through doctorpatient relationship we have to look for descriptions of both the patient’s and the doctor’s behavior. In doing so we see the literature of approximately 400 references shrink down to two references [ 13,321 .Unfortunately even in those two references no detailed advice on the management of the physician’s own behavior is given either. In other words, the whole literature on FAD-patientswhether traditionally clinical or specifically psychosomatic-provides no clearcut description of the comprehensive approach to this kind of patient. 3. Relation between Medical Practice and General Psychosomatic Knowledge: The Doctor’s Private Code We have learned that current psychosomatic knowledge on the management of FAD-patients offers little help of practical value. At best the primary physician is offered general guidelines. It is up to the physician to apply them individually, which of course presents tremendous difficulties, and its realization will depend on the physician’s private resources. In a recent study on the management of forty-two hospital patients with functional disorders five different qualities of a clinical approach were found [22]. They were based on the physician’s varying willingness to accept and to integrate psychosocial factors into the care of the patient. In an attempt to explain the results of this study two main factors seem relevant: 1) there is a lack of basic knowledge (not available, ignored, or both) enabling an integration of the data elicited into the whole-person of the patient; and 2) the physicians exhibit different personal capacities for defining and coping with their own feelings. It is understandable that these two factors greatly influence the clinical quality of the care of the patient. Consequently each physician develops a style of his own which is based on personal likes and dislikes but is hardly affected by a deliberate checking of factors which influence the doctor-patient relationship as induced by the doctor. In conclusion we may say that psychosomatic medicine and general medicine offer merely crude guidelines on the interactional and integrational level of patient care. Even the guidelines are not easily available and hardly applicable for the untrained physician in the usual clinical setting. Each physician develops a‘ private professional code when treating these patients. This code is usually untouched by psychosomatic medicine and it is located on a broad emotional
188 / Wolfram Schiiffel spectrum between FAD-patient = crock and FAD-patient = “poor guy” in need of sympathy.
4. Consequences Outlined in the Application of Interactional and Integrational Principles in an Individual Doctor-Patient Relationship; A Case Study Modes of Referral and Visits to the Doctor: The 54-year-old Frau A. K. had been referred for a psychosomatic consultation while still waiting to be examined in the outpatient department. I was asked to explore the reasons for her depression, which was in the referring doctor’s opinion related to her bodily complaints. Including the initial talk, there were four meetings between doctor and patient each, lasting about thirty minutes over a period of two and one-half months. Interaction: Establishing a Relationship The patient looked slightly older than her actual age but otherwise she seemed to be in good physical condition. She was neatly dressed and she had obviously just come from the hairdresser’s. Her gestures were controlled, but she seemed lonely. Her physician (the author) felt like a son sitting opposite a grieving mother. Nevertheless, he refrained from consoling her and told her about his own feeling. After ten minutes filled with bodily complaints, she reported on her son and her mother and she wept. Interaction: The Patient’s General Relationships Twelve years ago she, her husband (now 74), and her son (now 23), had gone to the States; five years ago they had come back because of the patient’s aging and lonely mother. The husband, who then had cancer of the prostrate, had grudgingly given in to his wife’s wishes for their return. A few months after the return the mother died and the son went back to the States. Neither patient nor husband, who were East German refugees, had relatives. Collecting Data: Illness History She complained of epigastric pain, heart bum, belching, and a bitter taste on her tongue from which she had suffered for about four years. She had visited altogether five doctors, had been admitted to a district hospital; a herniatomia had been suggested but not performed. Beginning Integration: Life History and Complaints Since the age of 30 she had regularly observed some gastrointestinal disturbances similar to the above ones. Professional help had not been necessary, however. There had been no major diseases in her life. The present disturbances started to become intolerable about four years ago when she came back from Detroit to a small Swabian town.
Evaluation Overall diagnosis. The contents o f the first meeting with the patient may be seen in the light of the two basic principles of interaction and integration besides the principle of collecting data. The physician’s task consists of integrating both
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data and characteristics of the relationship into an overall diagnosis/therapy. Establishing the relationship with the patient, the physician tried to register his feelings as clearly as possible; these were related to her loneliness, sadness and deep seated but hardly recognizable resentment. The physician felt that they were related to her husband, son and doctor (including himself). Integrating feelings and data into a picture of the whole person, the following overall diagnosis appeared to be likely although the results of the physical and laboratory examinations were not available at that time: A 54-year-old female patient whose 73-year-old husband has cancer of the prostrate and who feels deserted by her only child a son as a result of her own behavior. Digestive complaints which had been present almost all her life were aggravated after a series of threatening life events five years ago; they seemed to be cqused by functional disturbances of the upper gastrointestinal tract. She expected the doctors to diagnose those disturbances as somatically induced disorders.
Implications for therapy (overall therapy). Beginning with the first meeting, attempts were made to define the patient’s prevailing mood and to encourage her to verbalize her feelings and to relate them to the most important persons and events of her life. Attempts were made to let the patient know what the doctor’s sensations and feelings were when he listened to her. A characteristic passage of the first meeting was: “I cried a lot when the boy left and mother died. All right, he was 18 and he had grown up in that country. He does look after himself but nevertheless you do feel worried” [patient wept] . In the second meeting persons and events and somatic feeling states were brought together. The patient started to ventilate the impact of the life events: “Well, when the boy had left just after our return from the States, and when mother had suddenly died . . . it was then that I got all the stomach trouble . . . I even woke up at night, I was sweating and I felt panicky.” By the third meeting the doctor-patient relationship had become stable; the patient compared doctor and (beloved) son positively and was thus able to express her resentment; somatic complaints were no longer mentioned: “He [the husband] always blames me for being here [in Germany] ; h e tells me that I couldn’t help my mother anyway . . . ; h e doesn’t want to talk about the future nor about his illness. . . . He doesn’t understand me nor did he understand my son who used to come to me to talk things over . . . Talking to you is getting easier.” In the fourth meeting the ventilation of affects was precluded. For the first time within the last four years the patient was planning ahead, and the threat of chronic invalidity had been counteracted. “He [the husband] is old and he is not in good health; well he is ill. . . . I don’t know what will happen when he dies. My son will not come back, that’s what I am sure about. . . . I still have an exchange with an old lady in Detroit who is 70. She really is happy with her job as a pink lady in one of the Detroit hospitals.. . . [She explained
190 I Wolfram Schiiffel in detail how those voluntary visitors benefited from the visits at least as much as the patients themselves.] That’s what keeps her fit. Perhaps you are right and I should look for people to talk to.”
Follow up. Meanwhile the patient has started planning for the future. She thinks of becoming a pink lady in the little Swabian town herself. Her symptoms have vanished. When they reappear occasionally, she treats them with antacids and she is not worried by them as she used to be. Conclusions from Case History Establishing a relationship between patient and doctor includes 1) interaction between two partners, 2) collecting data, and 3) integrating data and main lines of interaction into the overall diagnosis. Characteristics of an overall therapy were followed up in all four encounters. Successive therapeutic steps were: the patient’s experiencing of affects, her relating of affects to persons/events and consequently to bodily sensations, her ventilation of interpersonal relationships including the doctor-patient relationship, and her planning of a concrete life period. At all stages I tried to communicate my perception of her feeling state to the patient. Additionally she was given medication ad libitum (antacids). In this case a diagnostic/therapeutic breakthrough was achieved through a deliberate application of the doctor-patient relationship and when: 1) the main affective characteristics of the interaction were identified and developed; and 2) characteristics of interaction were related to illness mechanisms and integrated into a whole person approach. This kind of breakthrough was not achieved in former visits to different doctors. Up to then the doctor-patient relationship was not applied as diagnostic/therapeutic tool. The reason for this is disregard of existent knowledge in medicine, lack of personal training and of adequate psychosomatic knowledge, and insufficient exchange of knowledge from the field of psychosomatic medicine. 5. Future Possibilities for the Introduction of Interactional
and Integrational Principles into Practice of Medicine Patients with FAD as Representatives of Today’s General Patients. In the above mentioned study on the management of hospital patients with functional disorders [22], no difference was revealed in the diagnostic and therapeutic procedures applied to patients with different functional disorders; similar observations have been reported [21]. Thus it can be accepted that the doctor’s attitude towards FAD-patients is representational of the physician’s general attitude towards all patients with functional disturbances. Moreover, those patients demonstrate no structural lesions nor gross physiological disorders when
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compared with the patient with coronary infarction, peptic ulcer or hypertension, thyrotoxicosis, and so forth. The aim of present medical practice is directed at diagnosis and treatment of structural lesions and physiological disorders. Thus the physician is trained to look for them and to accept them finally as the sole reasons for his patient’s breakdown. Psychosocial factors are regarded to be negligible in those cases. In my opinion one can apply the rule of thumb: if the doctor doesn’t see psychosocial aspects in “functional” patients he won’t see any in “organic” patients. TECHNIQUES FOR INTRODUCING INTERACTIONAL AND INTEGRATIONAL PRINCIPLES INTO PRACTICE OF MEDICINE Six years ago Weed proposed the introduction of problem-oriented patient records [35], and his methods have been practiced widely. Although Weed’s ideas represent a major step towards practice of comprehensive medicine by, as he says, “guiding and teaching” the physicians, the discussion on problemoriented records omits mention of principles of the doctor-patient relationship which is basic to any treatment situation. Resulting problems can be identified only if the main elements of the individual patient-doctor relationship are seen and integrated into the record. This relationship itself is a condensed replica of those situations in the patient’s life history when he needed help. The present relationship between the partners is characterized by the complementarity between help-seeker and help-provider. This is laid down in the rules of a contract between patient and doctor as recently pointed out by Engel [36]. The patterns of the complementarity have to be examined and thus interaction will be experienced by the individual physician. In order to achieve this goal of working on an affective level, adequate working styles have been described by Balint and co-workers [37]. Psychosomatic medicine has to establish and to systematize our knowledge of the pathogenetic and therapeutic effect of psychosocial factors which are of relevance to the patient-doctor relationship. A promising avenue in this field appears to be the work on the combined effect of life change and social assets on the outcome of illness [38,39]. The least studied area of integrating the behavioral aspect into practice of medicine still remains. This task has to be accomplished if psychosomatic medicine is to be established as a clinical approach. We are now at a stage which allows a clearer delineation of the setting, thus enabling the physician to get sufficient support for achieving a comprehensive approach: Only the physician who is in primary care of the patient will experience the implications of These considerations are based on a paper “Future Training in Clinical Psychosomatic Medicine” read at the constitution assembly of the West German Association of Clinical Psychosomatic Medicine, held in Ulm, March 2 , 1974.
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interactional and integrational principles of the doctor-patient relationship. Interactional and integrational implications have to be elaborated by techniques which are demonstrated by experienced clinicians [40] applying techniques as devised within modern liaison work [3, 411 . Those clinicians are the leaders of both interaction- and integration-oriented working sessions. This kind of training is based on affective learning and on empathy which can be taught. It clearly differs, however, from traditional psychoanalytic training and training in behavior modification. This training takes place within the physician’s actual working field as provided in private practice, hospital wards and outpatient departments. If psychosomatic medicine is regarded as a clinical approach as it is in this study, it has to stick to its roots-the patientdoctor relationship.
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22. De Dombal FT, Leaper DJ, Horrocks JC, et al: Human and computer-aided diagnosis of abdominal pain: further report with emphasis on performance of clinicians. Brit Med J 1~376-80,1974 23. Devor D, Knauft RD: Exploratory laparotomy for abdominal pain of unknown etiology: diagnosis, management, and follow-up of 40 cases. Arch Surg (Chicago) 96:836-39,1968 24. Martini GA: Personal communication, Wiesbaden, 1974 25. Jordan SM, Kiefer ED: The irritable colon. JAMA 93:592-95, 1929 26. Lipsitt DR: Medical and psychological characteristics of “crocks.” Int J Psychiat in Med 1~15-25,1970 27. Haemmerli U: Personal communitcation. Weisbaden, 1974 28. Harris ID: Relation of resentment and anger to functional gastric complaints, Psychosom Med 8:211-15,1946 29. Halsted JA, Schwarz R, Rosen SR, et al: Correlated gastroscopic and psychiatric studies of soldiers with chronic non-ulcerative dyspepsia. Gastroenterology 7:177-90, 1946 30. Klein HR: A personality study of one hundred unselected patients attending a gastro-intestinal clinic. Amer J Psychiat 104:433-39,1948 31. Sifneos PE: The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom 22:255-62, 1973 32. Moeller HC: Treatment of irritable colon. Mod Treatment 2:988-1002, 1965 33. McKegney FP: Psychosomatic gastrointestinal disturbances: a multifactor, interactional concept. Postgrad Med 47:109-13,1970 34. Clyne MB: The diagnosis, in Six Minutes for the Patient: Interactions in General Practice Consultation. London, Tavistock Publications, 1973 35. Weed LL: Medical records that guide and teach. New Engl J Med 278:593-99; 652-57, 1968 36. Engel GL: Enduring attributes of medicine relevant for the education of the physician. Ann Intern Med 78587-93, 1973 37. Balint M, Balint E, Gosling R, Hildebrand D: A Study of Doctors. London, Tavistock Publications, 1966 38. Rahe RH: Subjects’ recent life changes and their near-future illness susceptibility. Adv Psychosom Med 8:2-19,1972 39. Dudley DL, Holmes TH, Van Arsdel PP, De Araujo G: Quantification of psychosocial variables in intrinsic asthma: relationship to physiological variability. Second Conference of the International College of Psychosomatic Medicine, Amsterdam, 1973 (unpublished) 40. Uexkiill TH Von: Die Aufgaben der psychosomatischen Medizin in der Ausbildung zum Arzt. Verband Schweizer Medizinstudenten, Bern 1-13, 1973 41. Engel GL: Medical education and the psychosomatic approach: a report on the Rochester experience, 1946-1966. J. Psychosom Res 11:77,1967
