The Doctor
Is the doctor just a disease detective, a storehouse of facts and techniques, a computer programmed to be a "provider" of cost effective treatment? Or is s/he, like his or her patient, a person affected by the experience of illness?

Let me share with you some highlights of Michael Balint's book, The Doctor, His Patient and the Illness (1957). Insights from this book have helped me over the years to better understand the doctor-patient-illness relationship.

When Michael Balint, M.D. started research seminars to study psychological implications in medical practice, the first topic chosen was drugs. They discovered that "the most frequently used drug in general practice. . . [is] the doctor himself." However, there was no study of this drug, its dosage, frequency, allergies, side effects, etc. (Stanley, the patient described in Part I of this article with ill-defined joint disease, blindness, and paraplegia due to collapsed vertebrae, needed and received plenty of me and plenty of others.)

To better understand this drug, general practitioners and psychiatrists met weekly to discuss actual cases, studying the difficulties and successes in working to have a more comprehensive understanding of their patients, while recognizing the personal responses of doctors to their patients' illnesses (counter-transference).

They discovered that the family care physicians usually viewed their consultants as mentors, perpetuating the pupil-teacher relationship. Since the role that consultants take on for patients usually differs from the primary care physicians' role, there was often no captain of the ship. This produced a "collusion of anonymity." The family care doctors relinquished their primary care role to a degree, deferring to the consultants. The consultants provided diagnostic and therapeutic expertise. The patients ended up having less of the vital essence of personal doctor input.

My way of handling this with Stanley and with many other hospitalized and office patients is common to several practitioners I know. After rounding in the hospitals early in the morning, I come to my office and contact consultants who have seen or will be seeing my patients. I discuss with the consultants the nature of the patients' problems and establish a plan of action. These calls, which vary in number and length each day are a cause of chagrin both to the office patients who may have to wait and to the office staff. I persist with these calls because I feel they are absolutely essential to proper patient care.

The Balint seminars also found that doctors had an urge to prove they are good, kind, knowledgeable and helpful. Yet this backfired if the patient or the illness did not meet the doctors' expectations, leading to frustration and anxiety.

How did the doctors handle this frustration and anxiety? One response was to give patients reassurance. This had to be analyzed to see if it was given for the patients' sake or for the doctors'.

Another response of doctors to anxiety was the "Apostolic Function" Doctors have ideas of how patients should behave when ill, and what is right and wrong for them to expect and endure (for example, pain and anxiety). Even further, we doctors often find that we have a sacred duty to convert to our faith all the unbelieving and ignorant among our patients. We may have difficulties with patients who refuse, for instance, to accept our prescriptions for tranquilizers (in favor of healing or other complementary therapies), or our predictions that their diseases will be fatal within a given period (Roud 1990).

In contrast, imagine a "Mutual Investment Company" in which the doctor and patient invest in each other, not only to gather and provide information but also to enter a relationship of availability and duration. Their shared experiences lead to trust and respect, so that numerous threads bind the doctor and the patient. While this is more common in primary care, I should add that many consultants also form a "Mutual Investment Company" with their patients. A successful "mutual investment company" enables the doctor to be comfortable enough to take risks, to achieve "the courage of one's own stupidity," to feel free to be himself with the patient, and to use past experiences and present skills and intuitions without undue inhibition. I cannot think of a concept that has shaped and changed my approach to patients more than Balint's "Mutual Investment Company."

This process also acknowledges that every illness may also be a vehicle or a plea for love and attention.

Finally, the Balint process teaches that when in doubt, do not hurry, but listen and never advise a patient before you have found out what the real problem is - often a psychological one which is underlying the physical symptoms or disease. This is a new skill, requiring a considerable change in a doctor's personality and work style. Wise and aware doctors continue to meet in "Balint groups" to explore and work out these and related issues for themselves.

Foundations of a Healing Partnership
Having briefly explored some experiences of being patients and doctors, let us explore some foundations needed in developing a healing partnership. Since Hippocrates and Osler wrote about dehumanization, it is neither new nor exclusively the fault of high tech science. (Reiser and Rosen 1985).

Can dehumanization be prevented? To understand medicine and practice it as a human experience, Reiser and Rosen (1985) suggest four essential principles: competence, conceptualization of illness, acceptance and empathy (my order). Let us consider each of these in detail:

1. Competence in disease diagnosis and treatment means: factual knowledge, technical expertise and skills. Nobody would disagree that competence is important. I would like to include four additional meanings of competence which are less accepted and practiced:

a. We should seek reasons and stresses which may underlie illnesses. When someone becomes ill, it is important to ask "Why now?" "What new things are happening in the patient's life?" M.D. can mean Medical Detective.

b. We should not forget clinical judgement - how to decide with incomplete information. Think of an iceberg, in which only one-tenth is visible above the ocean surface. This requires imagination. As Albert Einstein said, imagination is often more important than knowledge.

c. Leo Galland, M.D. (1994) suggests another approach. He feels that we should individualize treatment based on identifying characteristics of the individual patient that are relevant (rather than plan treatment based on making a diagnosis of a specific disease entity and treating that). Such characteristics may include: What are the biochemical and/or emotional mediators of the patient's illness? Can we identify triggers that activate the mediators? What factors (biological and psychological, congenital or acquired) predispose the patient to develop the illness? What events precipitate the onset of illness?

d. Competence in medical treatment should include awareness of complementary and alternative medicine (CAM) modalities.

2. Conceptualization of Illness Here lies some of the most theoretical material of this presentation, helping to understand the plights of today's patients, their doctors and the entire medical establishment.

George Engel (1985a) feels that the way physicians think about, and act with patients is based on a paradigm deeply imbedded in medical education – yet one that is neither examined consciously nor critically. What is this model?

The current biomedical model, which has produced miraculous technological advances, resulted from the marriage of 17th century Newtonian mechanistic physics and the Church's permission to dissect human bodies - with the mind, soul, behavior and morals left to the church. This led to Cartesian dualism of mind and body, with the focus on diseases rather than patients. It produced the reliance on reductionism, which teaches that the understanding of a complex entity is best achieved by studying its component parts from which the whole can be reconstructed. We went from studying the heart, to studying the heart muscle cell, to studying its bioelectrical activity the biochemical reactions inside the heart muscle cell.

As doctors focused on finding the lesion, they began to view patients as simple machines and to look at themselves as repairmen. Although disease diagnosis and types of treatment may have improved, overall patient care has frequently suffered. While the biomedical model, reductionism, and "smaller is better" has not always led to better patient care, the biopsychosocial model usually has.

What is the biopsychosocial model? Engel (1985a) wrote that psychological and social factors operate as well as biological ones in patients' illness. This relies on systems theory.

What is systems theory? "Nature is ordered as a hierarchically arranged continuum of systems, with its more complex, larger units superordinate to the less complex, smaller ones."(Engel 1985) Since each system is also a component of a higher system, a person may be, for instance, the highest level of an organismic hierarchy while also the lowest level of social hierarchy. Each level or system has a distinctive organization and methodology for study.

What constitutes health? Health is based on achieving harmony in each system/level and between the systems/levels. Disharmony may arise in any system/level and spread to other systems/levels, depending on the ability of that system/level to adapt to change.

Norman Cousins made an observation, and I have also seen this in my fellow physicians. Because of the explosion of information, doctors often draw a box around the area of their expertise, learning as much information inside the box and withdrawing into it. By ignoring any information or inconsistencies outside the box, they also develop a distorted concept of illness. To develop a healing partnership, physicians must learn to live with ambiguity, uncertainty and not knowing all of the facts. (Reiser and Rosen 1985) They must also understand that their particular area of expert focus may only be one hierarchical component of the illness picture.

3. Acceptance is not an action but an attitude/ receptivity: the patient is not an object you do something to but a fellow person (like the doctor) that you embrace in your mind, heart, conscience.

Stephen Ray (1985), a sensitive plastic surgeon expressed his feelings about working with the severely deformed: "Before I enter the room to see such a person, I clear my mind of prejudices and preconceptions. I remind myself that all of nature is part of some universal order and is therefore harmonious and beautiful. Then, if I walk in the room and see a man or woman whose face has been scarred beyond recognition, I do not see the grotesqueness but find myself thinking of spiritual things - ancient craggy rock faces, gnarled old trees. It's odd - but with this attitude, where others find ugliness, I can discern beauty."

Reiser and Rosen (1985) present two models of acceptance:

a. Maternal acceptance - Picture a mother fondling a three month old infant. The mother holds the infant to her breast, often with her left hand, with the baby's head near her heart. One gazes at the other. The mother may stroke the baby and the baby may touch the mother's breast. There is little motor activity. The baby's tone is relaxed. Things are quiet and serene. But what if the baby is held awkwardly by a tense, disturbed or indifferent mother? A vicious circle may result. The baby may cry and tense its body with its back and neck arched. This agitates the mother, who may become even less available to give caring attention to the baby. . . who may then cry more. . . etc.

b. Illness often makes adults feel helpless and dependent like a baby. Enter the doctor, who may be afraid of disorganization and helplessness in him/herself and then, in an effort to reduce his or her uncertainty, probes the patient with questions and instructions. What the doctor really needs to do is to help the patient relax, feel protected, begin to trust - by opening up to, and resonating with, the patient; by listening; and allowing the patient's feelings to emerge (Reiser and Rosen 1985). The patient, sensing the doctor's discomforts, will hesitate to be open about his or her feelings. This leaves the doctor "protected" but uninformed about some of the "whys" underlying the disease.

4. Empathy is "The ability to fully understand and share in another's feelings, coupled with the ability to know that these feelings are not identical with one's own." (Reiser and Rosen 1985) If it is hard to define, it is harder to achieve. I am reminded of the Native American expression, "You can't judge someone until you walk in their moccasins."

Harry Wilmer (1987) distinguishes between pity, sympathy and empathy in the doctor-patient relationship, based on the identification of the self with the other.

a. Pity is, at the best, compassion, at the worst, contempt. It can be a defense against identification with the sufferer. (It is possible to feel pity yet have no clue as to what Stanley is really going through.)

b. Sympathy (Syn = together; Pathos = suffering) includes a merging of identities. It is the sharing of the suffering and pain as if it belonged to both participants. (How would I feel if I were in Stanley's place?)

c. Empathy means keeping one's own identity separate while entering imaginatively into the other's life experiences and emotions. (What does Stanley feel?)

Communication
Norman Cousins felt that all healing partnerships depend on effective communication. What power do words have? Nothing is more inevitable in serious
illness than the anxiety or even panic that accompanies
it. The words a physician uses can have a profound
effect on the patient's wellbeing. A doctor's words can
be gate openers - opening the way to awareness,
growth, recovery, mobilizing the will to live and setting
the stage for heroic responses. A doctor's words can be gate slammers - producing despair and defeat, impairing the usefulness of whatever treatment is prescribed and compromizing the healing environment which is central to the care of the patient.

It is a challenge to health caregivers to communicate negative information without crippling. We must present negative information to the patient as a challenge rather than as a death sentence.

Since patients are not equally adept at handling the truth, how do we deliver the truth? Does a doctor know enough about a human being to predict the outcome when bad news must be conveyed? Do we unload a truckload of informational bricks on a patient? Must we not abide by principles of informed consent? If doctors feel that they must mention every possible complication to a patient in order to protect themselves, don't we now have a conflict of interest between the patient's needs for humanistic treatment and the physician's need for legal protection? (Cousins 1985)

Norman Cousins illustrates the power of words to achieve goals other than complete cures. Cousins was asked by a hospital physician to see one of their patients, a judge who was very ill. Although he had always been a fighter, the judge was now willing himself to die and his character had changed drastically. The doctor felt that if the judge's family could be given just a week with him the way they used to know him - not in health but in the spirit as they had known him, this would be a most meaningful gift which they would treasure for the rest of their lives. Since Cousins was leaving for China the next day, he went to the hospital that night.

The judge, who was over six feet tall, was down to about 90 pounds, wasting away and barely able to speak. Cousins introduced himself, indicating that he was there because of the doctor's recommendation, in consideration of the familyWhat about the family?" asked the judge in a whisperWell, you know, cancer is the most contagious of diseases," Cousins saidNo, it's not," said the judge. Cousins clarified, "Well, it is contagious in the sense that grief is a virus, and sometimes the way we die helps to determine what happens to others; and when you look at the records, you will find that wives follow husbands within a few months and husbands follow wives - and the inability to handle grief is really a virus. You know, your family has always seen you as a fighter, and now you're going out of character." The judge said, "I gotcha."

The next day when they tried to hook him up to the intravenous he insisted that they feed him in the normal manner. Two hours later, he asked his wife to come over to play a game of bridge. When Cousins returned three weeks later, he discovered that the judge had died just two days before his return. He had not only lived out one week but lived out three and did so with spirit. He found his victory, and the family found its victory, in an altered context that was real (Cousins 1985).

Reiser and Rosen (1985) give us additional insights.

This is not the view that is held today in medicine.