Book
The Doctor, His Patient and the Illness
The Doctor, His Patient and the Illness reports on a research and training seminar that Michael Balint led at the Tavistock Clinic in London in the early 1950s, in which a group of general practitioners met weekly with psychoanalysts to discuss cases from their own practices. Working from these case histories, the book argues that the drug most often prescribed in general practice is the doctor, in person, and that nothing is known of this drug's dosage, side effects or toxicity. It examines what passes between doctor and patient, above all with the many patients whose complaints have no adequate physical basis. Balint describes how, at an early 'unorganized' stage, a patient offers the doctor a series of illnesses, and the doctor's responses help decide which of them is settled on and becomes 'organized'. Doctors tend to pursue a physical diagnosis first, ordering one examination after another to eliminate organic disease, which can fix the patient in a somatic presentation while the real trouble goes unaddressed; against this he calls for an 'overall diagnosis' that includes the patient's personality and relationships. He names the 'apostolic function', the doctor's urge to convert patients to the doctor's own idea of how one ought to behave when ill; the 'collusion of anonymity', in which responsibility is diluted among the general practitioner and the specialists until no one carries it; the lasting teacher-pupil relation between specialists and general practitioners; and the 'mutual investment company', the capital of shared experience that accumulates over years between a family doctor and the patients. He warns against premature reassurance and advice, and observes that a doctor who only asks questions gets nothing but answers, so that listening must be learned. The aim of the seminars was not to make practitioners into psychotherapists but to bring about a limited though considerable change in the doctor's personality, so that the doctor's own emotional responses could be used as clinical information. The book established the case-discussion method later known as Balint groups and became a classic of patient-centred medicine and medical education.
Main ideas
- The drug 'doctor': the doctor, in person, is the drug most often prescribed in general practice, yet its dosage, side effects and toxicity have never been studied.
- In the early 'unorganized' phase of an illness, the patient offers the doctor a series of illnesses, and the doctor's responses help decide which becomes the 'organized' illness.
- Pursuing physical diagnosis first, through repeated examinations meant to eliminate organic disease, can fix the patient in a somatic presentation; an overall diagnosis should include the patient's personality and relationships.
- The apostolic function: each doctor holds a firm idea of how a patient ought to behave when ill and tries, often unknowingly, to convert patients to it.
- The collusion of anonymity: when a patient passes between the general practitioner and several specialists, responsibility is diluted until no one takes it.
- A lasting teacher-pupil relationship between specialists and general practitioners keeps the practitioner deferring to the specialist instead of trusting knowledge of the patient as a whole.
- The mutual investment company: over years of illnesses shared, a family doctor and patient accumulate a capital of experience and trust on which both can draw.
- Premature reassurance and advice close off what the patient might say; asking questions yields only answers, so the doctor must learn to listen.
- The doctor's own emotional responses to a patient are clinical information, and training aims at a limited though considerable change in the doctor's personality rather than at making the doctor a psychotherapist.
- Regular case discussion among general practitioners led by a psychoanalyst, the method later called Balint groups, is a way of studying and training the doctor-patient relationship at once.
What it shows
- 1957
Michael Balint introduced Balint group
The Doctor, His Patient and the Illness (1957) reports the work of Balint's first discussion-cum-research seminars with general practitioners at the Tavistock Clinic. The training method it describes became known as the Balint group.