THE MEDICINE CALLED 'DOCTOR'
Csilla Moldovan (1), Albert Veress (2), Éva Veress (3).
1-GP, Mădăraş-Ciuc, 2-Dept. Psychiatry od District Hospital, Miercurea-Ciuc, 3Center of Public Health, Miercurea-Ciuc
Getting rid of the conventional way a scientific lecture is usually made up, we
will come up with an essay to show the essence of the notion found in the subtitle.
Michael Balint, in his work "The Doctor, his Patient and the Illnes”, which opened
new perspectives in understanding psyhosomatic disorders, launched the notion of
"The doctor as medicine". We are going to try an approach of the proposed idea in the
title from the point of view of this "medicine".
Presenting the medicine: "The doctor is an entity for the benefit of others."
(Scripcaru)
The active substance in that medicine is the PERSONALITY of the doctor. The way
the doctor takes part in the doctor-patient-illness relationship is determined by his
personality.
The personality of the doctor is determined by the influence of some
biological, psychological and social factors (the bio-psycho-social model /BPS/ by G.
ENEGEL), taken over and developed later by the Branzei school. This model derives
from the general theory of systems, and the doctor-patient relationship is also a
critical component of the BPS model. The doctor has to be familiar with the health
condition of the patient, his individual psychology, and also the social and cultural
environment he comes from. Otherwise, he would not be able to assess the emotional
response to the illness correctly, and grab the unspoken expectations of their relation.
The biological system stresses upon how the illness affects the biological
functioning of the patient, but the biological factors (condition, tolerance to effort,
dynamics etc.) also determines the personality of the doctor.
The psychological system shows the impact of the patient's psychodinamic
factors of motivation and personality upon his illness and his relationship with it. On
the other hand, these factors also shape the personality of the doctor, who has an
inherited mood. He comes to a proffessional motivation which influences his attitude
towards percieving and experiencing suffering, taking and dealing with traumas
linked to the profession such as professional failure or the death of the patient.
The social system emphasises the cultural and familial influences of the
appearance of the illness and the way the patient takes it. But the attitude of the doctor
is also affected by these factors. The doctor's personality is strongly influenced by the
way he percieves the ROLE of the doctor, and by the way his professional attitude is
influenced by the social demands towards that role.
The way the medicine is presented.
"Each doctor creates a unique atmosphere" (M. Balint)
The overactive doctor: authoritarian in the doctor-patient relationship, leads
the treatment.
The partener doctor: equality in the doctor-patient relationship, treatment goes
on in collaboration with the patient.
All-knowing doctor: paternalistic, treatment is conducted by the doctor with a
teacher-student-like subordination of the patient.
The friend doctor: in most cases such a relation doesen't work.
The Balintian doctor: the best ailment in treating psychosomatic disorders "The doctor as medicine." (M. Balint)
Advantages: reveals the pathogenetic effects of PS disorders; focuses on PS illnesses
as a consequence of poor communication, isolation, and problems of making a living;
satisfies the communicational needs of the patient; makes a survey of all possible
solutions to the patient's problems; reveals new perspectives in solving these
problems.
Characteristics and effects
Confines to the saying: "Nil nocere."
PS illnesses are considered to be a consequence and an expression of
problemes of existence, of communicational hezitations and disturbances. The best
medicine will be the doctor who satisfies the patient's need of communication. The
'Doctor medicine' has some characteristics linked to these particular effects.
Empathic capabilities: putting himself into the patient's situation, and the
possibility of understanding the problems from the patient's point of view as well.
Remember: the patient expects understanding!
Capability of listening in silence: that is an essential characteristic of the
medicine, resulting in the possibility of discovering the ethiology of PS symptoms.
Keeping silence and listening will eventually break the patient's resistance, the first
step towards communication.
Capability of listening without judging: will help assess the objective situation
of patient. The doctor should remember, that, deriving from his profession, not one
human aspect should be alien or ununderstandable for him!
Tolerance, flexibility and sensitivity with the patient: a communicating doctorpatient relationship will be settled, shaping emotions and making the patient be
aware, assesing the emotional dinamics of the relation.
Capability of changing his emotions towards the patient. Will produse a
change in the situaion of the patient (a new way of looking at things, an alternative to
the treatment, becoming more distant, getting out of a nonfunctional relationship), the
possibility of accepting a terminal situation (death, incurable disease). All these will
increase the efficiency of the doctor in desperate cases (cancer, chronic diseases).
Capability of intuition and realization of the awareness of the transfer and
countertransfer in the doctor-patient relationship. Will help the doctor to control his
emotions towards the patient, being aware that the patient has a set of expectations,
views, emotional demands brought into the relationship. On the other hand, the doctor
himself will develop reactions, views and emotional demands converging onto the
patient. Doctors also have unconscios and unspoken expectations with the patient.
Capability of accepting that recovery means autonomy. This eliberates the
pacient from the relationship.
Pharmacokynetics
"The way the doctor offers himself to the patient depends on his personality rather
than the needs of the patient." (M. Balint)
The pharmacological action of the 'medicine' can be observed through the
quality of the doctor-patient-illness relationship. The ENEGEL BPS`s model is valid
for both the doctor and the patient, while the doctor-patient relationship is a critical
component of the BPS model.
The pharmacological action of the 'medicine' lies in: assessing the doctorpatient relationship; assessing tensions in the life of the patient; a good understanding
of complex interpersonal factors such as transfer and countertransfer; the correct
assessment of the dynamics of the doctor-patient relationship.
How does the 'doctor' as a medicine act upon BPS? PS symptoms are diffuse,
they do not fit the conventional symptomatology of diseases. They rather express vital
situations the patient cannot or doesn't want to deal with otherwise. Casually,
rationing hinders the process of becoming aware of the illness-generating problems.
In a lucrative relationship, where communication is possible, the doctor can prompt
the 'Balintian Flash', by spontaneously shared thoughts, free associations; this will
certainly cast light upon the basic problems of the patient 'here and now'.
The Placebo effect depends on: the efficiency of the 'medicine'; trust in the
curing doctor. The effect can be correlated with the apostolic function of the doctor,
who converts the patient to his own ideas.
The pharmacokynetics of the medicine called 'doctor' is also influenced by the
ritual the medicine is administered, a sort of 'magic ritual', with considerable effect
on the patient, thus increasing the therapeutical efficiency of the medicine.
The indications for the medicine depend on the psychosomatic symptoms,
which are linked to a vital problem which may be etiopathogenic factors in the
genesis of the psychosomatic disorders: alienating and social izolation; lack of
communicational possibilities; job difficulties; lack of satisfaction in love; lack of
feelings; collapsing of traditions; uncertain daily existence; no perspectives for the
future; accepting and idealizing compromises; moral crisis.
The origin of PS disorders and the availability of the doctor as medicine.
The ethiological factors lead to an actual unbearable situation, thus creating a nervous
state equal with an imminent collaps, the afflicted person experiencing an acute need
for help. In this situation there is nobody to receive the cry for help but the body of
the patient itself, which will turn the problems from the outside into somatic inner
ones, and all this will make him call the doctor.
Dosage
Determined by the gravity of the PS disorders, tolerance towards the medicine,
and the development and intensity of side effects. A possible antidote against
overdozing would be giving up the relationship.
Limits in administering.
The efficiency of the medicine is not always a spectacular one. It works within
a two-directional relationship. Its effects are under the influence of the dynamics of
specific relations between humans anywhere else. BPS factors also limit its action. It
will affect not only the patient, but everybody around. Efficiency depends on the
personality of the doctor, who is the really active substance of the medicine.
Occasionally, this medicine equilibrates the system. The family is a BPS
system itself. It functions according to a specific dynamics. The doctor medicine may
be considered to be a shock absorber in the system. Any member of the family may
flatter the doctor somehow, as he knows the problems well. Thus conflict is drained
through the doctor, who is or is not part of the family at the same time. Only by being
present, he absorbs the negative shocks, making it possible for the others to live along
with the problems. The system keeps on going against expectations, even if problems
persist. The doctor may also feel uncomfortable in the family, experience unpleasant
emotions while playing his therapeutic role, thus limiting the efficacy of the
'medicine'. We must also accept, that recovery is not always possible, and the
CHANGE does not add up to being a condition for a recovery. The 'medicine' cannot
replace the poor social protection, the ethnic, cultural and religious beliefs, the
financial and social situation of the patient, BUT it will more or less change the
thinking of the patient, his status in the family, and will certainly help him get through
the emotional experiences due to the PS disorders.
Side effects
The countertransfer of the doctor is the result of the influence of the patient on
the unconscios mind of the doctor, and this will lead to an improper attitude with the
patient: agressiveness, anger, indifference, keeping the patient unmotivated inside the
relation, iatrogenic effects.
Patient depends on his doctor. That is a consequence of regression of patient,
of transfer and irrational projections upon the doctor. This hinders the patient from
regaining autonomy (in fact, he doesn't want it), and the psychological recovery
which would free up the relationship.
The doctor may crave for power (Adler). This is to hide his inferiority as a
medicine, he may feel incapable of making a relationship and to communicate with
the patient. His anxiety, the uncertain diagnosis will only add to it.
The doctor may become a little dictator to the patient. (Lachland). Dictatorial
behaviour may lead to somatic and psychic disorders.
Doctor's self defence. It is an adverse reaction as a defence against
professional frustrations. Let's mention the behavioral stereotypes: a. refusing the
patient, b. doctor will suggest that PS afflicted patient has in fact no illness at all, c.
endless referrals to other specialists and paraclinical investigations.
Exagerating the angelical function: a. the doctor tries to convert the patient to
his conception about the illness, b. he feels omnipotent as if he knew all, even if he is
not aware of it, c. the doctor is vulnerable to a criticising patient, and feels hurt if
patient leaves him.
Special notice on using the 'medicine'.
There are three sorts of treatment: profilactic; trapeutic; intaining. Use and
eficacy of the medicine called 'doctor' also depends on the length of treatment. The
best a doctor is quoted, the more patients he must deal with. Consequently, he will
have less time to communicate with them, thus more patients will leave him for other
possibly less efficient doctors, but having more time at their disposal.
Referencies:
Scripcaru Gh., Ciornea T.:Deontologie medicală Ed. Medicală Buc., 1979, cit. de Cucu C. Ioan,în
Psihologie medicală, Ed. Litera, Bucureşti, 1980, pag. 151
Tudose F.: O abordare modernă a psihologiei medicale, Ed. Info medica, Bucureşti, 2000, pag. 69
Bálint M: Az orvos, a betege és a betegség. MPT kiadás, Budapest, 1990.
Knoepfel K.H.: A háziorvos pszichoterápiája és az orvos-beteg kapcsolat, in: A Bálint -csoportok
elméleti és gyakorlati kérdései, szerk.: B. Luban-Plozza és H.H. Dichaut, Animula kiadó, Budapest,
1988, pp. 19-25
Moldovan, Cs., Trif, A.B., Zielinski, R.:Îndrumător metodologic pentru grupul Balint. Ed. Quadrat,
Botoşani, 1997.
Veress A., Veress É.: De la vis la împlinire. Ed. Status, Miercurea Ciuc, 2003.