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Good doctor, bad doctor—a psychodynamic approach

BMJ 2002; 325 doi: (Published 28 September 2002) Cite this as: BMJ 2002;325:722
  1. Jeremy Holmes, consultant psychiatrist/psychotherapist.
  1. North Devon District Hospital, Barnstaple, Devon

    Let's face it—we doctors aren't saints. Have we not all sometimes felt bored and irritated by certain patients, longing for the consultation to end? Can any doctor honestly say that he or she has never felt a flicker of sexual interest in a patient? Have we never—and post-Shipman it is very difficult to say this—imagined the death of certain patients and the relief that would bring, not just to them but to us, their impotent carers? Do we not at times resent the demands of people for whom illness seems to have become a way of life? Whose thoughts have not sometimes drifted off towards their own concerns—to the need for sleep, food, or distraction or to some family, career, or future plans?

    We are merely using our patients to bolster our own fragile sense of competence and health

    Moreover, perhaps rather than being motivated by altruism and scientific integrity, we are merely using our patients to bolster our own fragile sense of competence and health. Most of us look reasonably healthy, physically and mentally, as we stride about “our” hospitals and surgeries, strong and powerful in contrast to the vulnerability and distress with which we are surrounded. Are we not treating ourselves, our vulnerability and fear, as much as our patients?

    So is none of us really fit to practise? In confessing to these failings, am I writing a professional suicide note? What are we to do with these normal human reactions? Are we to ignore them, repress them, speak out about them—or can we use them in the service of our work?

    The key to good doctoring is not regulation, but the ability to put ourselves in our patients' shoes

    The crucial distinction is between thought and action. We aim, as far as possible, to be pure in word and deed, but we can allow ourselves to be as ugly as we like in thought. The more aware we are of our reactions to a patient—however bizarre, irrelevant, or unprofessional these may seem—the less likely we are to use the power imbalance between us to act in untoward ways. When bad things happen between doctors and patients it is usually due to a confluence of the unconscious needs of both. If the lonely doctor had been aware of and been able to articulate the extent of his sexual fantasies he would have been far less likely to end up in bed with his sexually abused and depressed patient. I often find that a few minutes' irreverent moaning about patients with colleagues before a ward round leads to better and more compassionate consultations.

    The feelings a doctor has, or actions he or she carries out in relation to patients, are often a manifestation of the patient's inner world, via a mental mechanism known as “projective identification.” If a doctor is bored with a patient, this may be because the patient is feeling dull or uninteresting or is angry about something but cannot express the anger. Excessive worry about a patient may be the result of being infected by the patient's anxiety—but out of proportion to the objective situation.

    The GMC prescribes do's and don'ts for doctors. Although these are undoubtedly useful, most doctors consciously subscribe to them anyway, and the question of why bad or harmful practice continues remains unanswered. I believe this is because, like all human beings, we are less coherent than we like to think, and are motivated by forces of which we are unaware as much as by the conscious wish to heal and do a good job. Ultimately the key to good doctoring is not regulation, but the ability to put ourselves in our patients' shoes—to imagine what it might be like to be on the receiving end of our treatment. There are many ways to acquire this capacity for reflexive practice: role play, listening to users' perspectives, being a patient (through illness or through therapy or counselling). “Balint” groups, widely used in general practice, attempt to explore doctors' feelings about their patients through facilitated case discussion. I believe that all doctors should attend Balint-type groups in their training.

    The search for the good doctor is an illusion—our unconscious minds will make sure of that. The psychoanalyst Donald Winnicott reassured mothers that to be “good enough” was preferable to striving to be ideal. Mothers who are good enough provide children with the opportunity to learn to cope effectively with disappointment and failure in the context of love. Similarly, if we can without complacency bring our good and bad parts together to become a good enough doctor, we should be content. More importantly, so will our patients be, despite sometimes feeling let down by us.

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