“The nurse explains the treatment in more detail – they are much better at it.”
— Quote from an orthopaedic surgeon at a conference attended by the CLAHRC WM Director
The CLAHRC WM Director was sorely provoked by the statement above. The doctor here is self-consciously abrogating responsibility for holistic care by restricting attention to physical problems and leaving psychological matters to others. This duality of role – the doctor sorts out the physical problem, while someone else, nurse, counsellor, provides compassion and counselling – is often implicit, even if not spelled out in the stark terms captured in the quote above. Of course no-one, not even the above orthopaedic surgeon, is saying that doctors do not need to be good communicators – the selection test for GPs covers empathy, sensitivity, and information exchange, for example. But is that it? If the patient is deeply distressed because she has reached the point where she has to start dialysis, or has been found to carry a genetic condition, then who should attend to psychological needs – needs that go beyond simply providing information kindly and showing the right affect? Some would say that counselling, discussing feelings, and providing a safe emotional place where the patient can express anger and grief, fall into the realm of a professional ‘counsellor’.
There is, however, an alternative view – in fact this Director’s view. It goes like this – intimate involvement with the patient’s physical condition provides a conduit to improved psychological care. The theory in play here is that the medical consultation does not start from a neutral position, and that the assumptions built into the initial consultation represent a potent force for good. Building on this, the doctor’s behaviour becomes part of the treatment – a therapeutic alliance. The doctor-patient relationship once formed can easily and naturally be expanded to cover a broader remit – to include, for example, not just the clinical problem, but the feelings it evokes. If this theory that the intimacy inherent in the doctor/patient relationship provides a therapeutic opportunity is correct, then it should be exploited. This has implications for medical education and for service organisation. Education would have to include preparation for consultations that are not ‘transactional’, but include dealing with feelings; sharing emotions. Service change will be radical. Appointment slots will need to be flexible – the standard short consultation would need to be rethought. And skill substitution will be needed so that some of the more routine ‘physical’ components of care can be devolved to other cadres (such as physicians assistants). This will leave doctors with more time for the really important job of talking to patients.
But is the premise correct? The famous Family Physician, Michael Balint, certainly thought so – he expressed the idea with the metaphor, “the drug, doctor.” So I call on authority in support of my premise. But I also call on personal experience and some empirical evidence. As a specialist in foeto-maternal medicine, I worked closely with the psycho-analyst Susan Godsil. She emphasised the importance of bringing patients’ feelings to the surface during consultations. Most of my patients had experienced a deep personal loss in a previous pregnancy. Inviting them to express feelings would often unleash strong emotions. I came to see this as success – just because tears are not shed, does not mean that they are not there. I put the idea, that a doctor could achieve in a short period of time what a counsellor could achieve over many sessions, to an empirical test by conducting an RCT of doctor counselling alone versus doctor counselling followed by a series of psychological counselling sessions. The results was a dead heat. So a doctor willing to put time aside to speak intimately with patients, and do the psychological ‘work’ necessary to conduct such a conversation, can achieve in an hour as much as a trained therapist over about six hours.
Spooling forward, our CLAHRC has an interest in how people cope with transitions in health – reaching the point where dialysis becomes necessary for patients with advanced kidney disease, for example. My colleague, Dr Gill Combes, is leading this work, and I hope we will have an opportunity to explicitly test my hypothesis. Our pilot work has shown that kidney specialists are apprehensive of getting involved in counselling, but would welcome support in overcoming this perceived barrier. None of us think that doctors can do it all – that would be arrogant. We are not saying that people who have severe psychopathology do not need specialist help. Rather, we are concerned with the severe distress that falls within the normal range for people dealing with severe illness or loss. Here we hypothesise that doctor involvement in counselling and, when necessary, demonstrating compassion, could be highly cost-effective by virtue of the purchase that ‘medicine’ has had on the human soul from time immemorial. The doctor patient relationship is the foundation for all else in medical practice.
— Richard Lilford, CLAHRC WM Director
No sooner had I put the above post ‘to bed’, than I encountered two consecutive salient articles in the BMJ. The second of these, by David Loxterkamp, a rural GP from Maine, seemed to agree with my line of argument. He writes “…our work entreats us to risk affection and enter into the most delicate areas of a patient’s life, where lies the source of pain but also healing.” Why can’t I write sentences that good!
The first article, by consultant clinical psychologist Raymond Chadwick, is also beautifully written. But it seems to come to the opposite conclusion – the patient has the right to expect courtesy and consideration, and the clinician must recognise psychological distress, and act in the patient’s best interest. But compassion – that, he says, is a gift over and above what can be expected. But I think this is to give up too easily. Yes, I agree that compassion should not be a health service target and that clumsy attempts to mandate it will most likely backfire. But what I believe is this: compassion can be developed through exercise, and reinforced by role models. The greatest gift a medical teacher or undergraduate dean can give students is the practical demonstration of compassion at every opportunity. It takes a bit of brass neck for a doctor to disagree with a professor of psychology on a point of psychology. But I really do disagree with Raymond Chadwick when he says that compassion cannot be expressed if it is not felt. On the contrary, there will be times when it can’t be felt if not expressed. So, fake it if you have to, but keep on at it. You will find that it becomes a natural part of your persona – conscious competence will become unconscious competence (see previous blog post). Sometimes you will fail in your compassionate duty. Admit it, forgive yourself, then try again.
— Richard Lilford, CLAHRC WM Director
- Balint M. The Doctor, His Patient and the Illness. 2nd London: Pitman Medical, 1964.
- Lilford RJ, Stratton P, Godsil S, Prasad A. A randomised trial of routine versus selective counselling in perinatal bereavement from congenital disease. Br J Obstet Gynaecol. 1994; 101(4): 291-6.
- Loxterkamp D. “Complicating relationships” – the water that doctors breathe. BMJ. 2015; 351:h4185.
- Chadwick R. Compassion: hard to define, impossible to mandate. BMJ. 2015;351:h3991.