The Doctor, his Patient and the IllnessBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39384.467928.94 (Published 01 November 2007) Cite this as: BMJ 2007;335:941
- James Curran, GP locum, Glasgow
This book arose out of a series of seminars that the author, a psychotherapist, conducted with general practitioners at the Tavistock Clinic in London in the 1950s. At these seminars the GPs presented case reports to discuss aspects of the doctor-patient relationship. What became of interest was those patients who presented repeatedly to GPs with psychological or physical complaints but whose investigation findings were often normal and who were difficult to treat satisfactorily. About such patients Balint came to the conclusion that “some of the people, who for some reason or other, find it difficult to cope with the problems of their lives resort to becoming ill.”
The Doctor, his Patient and the Illness documents the case histories of several of these patients in detail, including their GPs' attempts at treatment, and the subsequent group discussions. Balint discusses several themes arising from the seminars, such as the idea of the doctor as “drug”—in particular how a doctor's actions influence how a patient responds to illness and treatment.
These patients seemed harder to help because GPs had to rely on the standard medical model (“elimination by physical examination”), learnt from hospital consultants (“perpetuation of the teacher-pupil relationship”). In many cases where a patient passes through the hands of several specialists, each looking only at one aspect of a problem, a diffusion of responsibility can arise, even for important decisions (“collusion of anonymity”). Balint goes on to discuss ways in which GPs could help such patients, including through psychotherapy.
Balint's book remains known among most GPs, even if they have not read it. Are its themes still relevant, given the changes in society and medicine, a half century after it was published? Some are directly relevant. How the “drug” (doctor) is prescribed still remains important, and a “collusion of anonymity” would seem to be enshrined in protocols. Many patients still come to their GPs with recurring complaints that have no obvious physical cause but with underlying psychosocial problems. Are GPs now better able to deal with such patients? Vocational training has ensured that GPs can assess patients from more than just a medical model, but how GPs could (and indeed whether they should) try to intervene in treating what may be deep seated personal psychological or social issues continues to be debated, and it is unlikely that many GPs attempt psychotherapy.
So, although this book is still important for the way it opened the lid on doctor-patient interactions, and because many of its messages are still relevant today, the ideas it contains need to be continually re-evaluated and added to.
The Doctor, his Patient and the Illness
By Michael Balint
First published 1957