Who's in the
waiting room?
That more and more of the general practitioner's time is being taken up by the demands of mental and emotional illness, has become almost a cliche of medical thinking. But what does it mean? If we try to look at the prevalence of mental illness in general practice, to ask, 'How much is "more and more"?' we find only contradictions and confusion. For example, while one observer records the percentage of episodes of emotional (as opposed to physical) illness as 3*7, another gives the figure as 53-7. The difference is remarkable, to say the least.
How can it be explained? A 30-year-old housewife brought her second child to me to be immunised. As she stood to go she mentioned that she had been having a lot of
backache. I replied, 'I notice that you haven't be^ to see me about your contraceptive cap since tbbaby was born'. She began to cry and told fl1 that she had always hated using the cap and frightened of starting on the Pill. I reassured hc about the safety of the Pill, and she said that st would like to try it. She was able to see that tfe backache was a form of contraception ('I cart tonight. My back hurts too much') and smil? ruefully at my explanation of the cause of bc symptom. When she left the surgery there was glow of mutual satisfaction between us. It was some months before I came to reali5 how I had completely ignored the signs of b? sexual uncertainty and how, far from examini?
^ the general practitioner is seeing more mental ill-health, it is because he is face to face with his patients' greater expectation of human happiness'
BY MARSHALL MARINKER
who is
a
Grays, Essex "cr
honestly,
I had
merely substituted her formuation of the problem (the backache) with my own 'her inability to establish a proper contraceptive
regime).
The case illustrates the elementary problems recording observations in general practice. How should the encounter be labelled? As an immuni?t
??ical procedure? Advice on birth control? Puerperal depression? Or is it not better to face the fact hat there is no handy diagnostic shorthand to sum Up the complex reality of the illnesses that people r,ng to their general practitioners? It may be painful heresy in a scientific age? rnore than half in love with the analysis of measure-
it is ment?but octor tries to take
fact that however hard
a
the
epidemiological photograph his practice, the developed print only reveals a shadowy photograph of the doctor himself. an
heading role ^hat
marks the general practitioner's role is much a special kind of skill as a special 'nd of responsibility. Recognising his isolation as a Painful condition the planners of medical care have suggested a cure. Their panacea is teamwork, and the general practioner has been awarded the eading role in the team. To quote the 1963 Minisof Health Report, 'The field of work of the
?pt
so
try
amily doctor',
on
the subject of the Mental Health
Services, 'All the services hospitals, local authorities, .
.
and voluntary workers, exist
provided by clinics, employment officers
.
to support the family and should be co-ordinated through him'. But teamwork in the care of the individual Patient, far from providing more comprehensive c.are, provides merely fragmented care and a dilut'?n of personal responsibility. Despite the lavish Sifts which the physical sciences have given to ^edicine, medical care, in the sense of the professional handling of a total illness situation in the '^dividual, is essentially a person to person rela-
doctor
tionship. a
The patient
cannot have a
team, however well
however well led. Having said so
organised
relationship
that team and
much it should be added that is one area in which a team can be of enormous value. I refer to the field of family medicine ar*d to the paradoxical position of the family doc*?r- As a family doctor, the general practitioner has a Unique access to the structure of the family unit, hile he may derive all sorts of added insights
*here
comin 7
from this knowledge, the fact that he stands in absolutely similar professional relationship to perhaps three generations of a family involves him in a conflict of loyalties no less serious than those which lawyers are at such pains to avoid. For example, if he is able to help a daughter to tear herself free from a dominating mother, how can he deal with the mother's misery, and the pain which the daughter's behaviour will inflict upon her?
High
drama
A bright
10-year-old schoolboy suddenly
devel-
oped severe epileptic seizures. Three months later his sister, attending a grammar school, was admitted to hospital in coma. She recovered rapidly and detailed investigation revealed nothing amiss. She was discharged home, but the episodes recurred and each time she was rushed to the hospital for lumbar puncture. During all this high drama her mother showed only a minimal interest in what was going on, and for weeks her father made no effort to discuss the problem with any of the doctors involved. Slowly, the outlines of the problem became discernible: the 14-year-old girl was already physically a woman and her mother was struggling to keep her a child, the father was reacting violently to her awakening sexuality. The boy's epileptic fits not only occasioned all sorts of frightening fantasies in the girl, but cemented the family feeling of secrecy and shame. If the doctor is to work with any one of the 'parties' to this kind of situation?and the legal term is appropriate?there has to be a heightening of the doctor/patient relationship. The exclusive nature of this alliance between the doctor and the patient is often expressed by the patient either as a shutting out of the rest of the family ('Mum just can't understand how I feel') or as a shutting out of the rest of the medical profession ('I tried to talk to the specialist about all this, but he wouldn't listen to me').
Watching brief In this case I referred the boy to a consultant with an interest in epilepsy. We decided that the consultant would deal with the boy, that his P.S.W. would try to take on the mother, that I would continue to treat the girl, and that we would all keep a watching brief on the father, whom we all felt was the key to the situation. The details of the treatment and of its successful outcome are not relevant here: what is relevant is the
psychiatrist
demonstration of meaningful teamwork. Each of us adopted a therapeutic role to a whole patient. Had we, instead, applied ourselves, the psychiatrist to his notion of the psyche of each member of the family, the P.S.W. to her notion of the psycho-social milieu of the family, and myself to some vague abstraction of general care?and this is usually what is meant by teamwork?the result might have been very different. What help can the general practitioner expect from the mental health services? Specifically, what can his expectations be of the consultant psychiatrist, and when should he refer to him? It is easier to define those cases where referral is absolutely indicated. In the classical psychoses, neuroses, and mental subnormality, the relationship between the psychiatrist and the general practitioner is quite clear-cut. Having said this, one must add that these cases form a very small minority of the mental health problems with which the general practitioner deals. Personal dilemmas of his problems, however, the has little to offer the general practitioner. The anxious patient, the unhappy patient whose personal dilemmas have boiled over into an illness, for the most part receives little of material value from a consultation. Does it really help the general practitioner when the psychiatrist reformulates for him the problem that he calls 'John Smith', as 'inadequate personality with anxiety and phobic symptoms'? Apart from a few honourable exceptions, the patient's follow up consists of a juggling with tranquillisers and anti-depressants and so-called supportive psychotherapy. That is, a therapy that is hardly ever supportive and certainly never psychotherapy. It may be a hard thing to say, but perhaps the most valuable part of a psychiatric referral is the long waiting list in the outpatient department?it is so much better, both for the general practitioner and his patient, to travel hopefully than to arrive at the reality. The reason for this unhappy state of affairs is not that psychiatrists are failing to do their job, but rather that both the general practitioner and the psychiatrist have failed to agree about the nature of psychiatry. If, however hard we look for it, we are unable to determine the proper frontier of psychiatry, it is only because the frontier is a medical no-man's land between conflicting theories and attitudes. Here we come to the nub of so many of our problems: to the explanation of the vastly different levels of psychiatric illness reported from general practice; to the blurring of therapeutic roles and the failure of teamwork; to the breakWith the
psychiatrist
majority
down of the dialogue between the general practi' tioner and the consultant psychiatrist. The handling of a schizophrenic crisis is clearly the speciality of the psychiatrist. The handling of a backache clearly that of the general practitioner. But as we have seen, the illness that is labelled 'backache may have other portents. Is this situation illness or mental illness? Is it a psychiatric prob' lem? The Cartesian notion of man as a ghost in 3 machine will not work for general practice. We have had to learn to think in terms of whole-person pathology, and even concepts like 'psychosomatic disease' have a limited usefulness once we come to see that all illness has a symbolic meaning, and that this symbolic meaning may be more important than its 'scientific' description. If we can accept this, if we can deal with the whole person, we shall restrict our referrals to the psychiatrist to those cases of classical psychiatric illness which he has been trained to recognise and deal with, and cease to use the psychiatric referral as a means of rejecting a patient whose illness situation will not fit into the diagnostic strait-jackets that we were taught at our medical school to recognise as propef illness.
physical
Conforming society I started
by saying that the general practitioner increasing amount of mental ill-health. It is impossible to say exactly what this may mean-
sees an
but I suspect the statement contains a number of truths. Despite the seeming liberalisation of society, the mass media have made us a more conforming society than ever before. The less permissive the society, the greater the strain on those who deviate from the norm?what has been called 'the psychosis of the consensus'. But we are also becoming more sophisticated. The result of penicillin, modern surgery, and the stupendous advances in public health, is a patient whose expectations about the quality of life are infinitely higher than ever before. The woman who a generation or two ago was succumbing to the chronic disease of repeated childbirth, will come to her doctor today because she cannot achieve an orgasm or because she has become short-tempered with her baby. She may bring the problem openly, and often today she does, or she may bring it wrapped up in the tradi' tional parcel of physical complaints that her doctor has been led to expect. If the general practitioner is seeing more mental ill-health, it is because he is coming face to face with his patients' greater expectation of human happiness. Far from being the sign of a sickening society, this may well be the sign of a sane society in the process of reexamining its values and its needs.
waiting room?
That more and more of the general practitioner's time is being taken up by the demands of mental and emotional illness, has become almost a cliche of medical thinking. But what does it mean? If we try to look at the prevalence of mental illness in general practice, to ask, 'How much is "more and more"?' we find only contradictions and confusion. For example, while one observer records the percentage of episodes of emotional (as opposed to physical) illness as 3*7, another gives the figure as 53-7. The difference is remarkable, to say the least.
How can it be explained? A 30-year-old housewife brought her second child to me to be immunised. As she stood to go she mentioned that she had been having a lot of
backache. I replied, 'I notice that you haven't be^ to see me about your contraceptive cap since tbbaby was born'. She began to cry and told fl1 that she had always hated using the cap and frightened of starting on the Pill. I reassured hc about the safety of the Pill, and she said that st would like to try it. She was able to see that tfe backache was a form of contraception ('I cart tonight. My back hurts too much') and smil? ruefully at my explanation of the cause of bc symptom. When she left the surgery there was glow of mutual satisfaction between us. It was some months before I came to reali5 how I had completely ignored the signs of b? sexual uncertainty and how, far from examini?
^ the general practitioner is seeing more mental ill-health, it is because he is face to face with his patients' greater expectation of human happiness'
BY MARSHALL MARINKER
who is
a
Grays, Essex "cr
honestly,
I had
merely substituted her formuation of the problem (the backache) with my own 'her inability to establish a proper contraceptive
regime).
The case illustrates the elementary problems recording observations in general practice. How should the encounter be labelled? As an immuni?t
??ical procedure? Advice on birth control? Puerperal depression? Or is it not better to face the fact hat there is no handy diagnostic shorthand to sum Up the complex reality of the illnesses that people r,ng to their general practitioners? It may be painful heresy in a scientific age? rnore than half in love with the analysis of measure-
it is ment?but octor tries to take
fact that however hard
a
the
epidemiological photograph his practice, the developed print only reveals a shadowy photograph of the doctor himself. an
heading role ^hat
marks the general practitioner's role is much a special kind of skill as a special 'nd of responsibility. Recognising his isolation as a Painful condition the planners of medical care have suggested a cure. Their panacea is teamwork, and the general practioner has been awarded the eading role in the team. To quote the 1963 Minisof Health Report, 'The field of work of the
?pt
so
try
amily doctor',
on
the subject of the Mental Health
Services, 'All the services hospitals, local authorities, .
.
and voluntary workers, exist
provided by clinics, employment officers
.
to support the family and should be co-ordinated through him'. But teamwork in the care of the individual Patient, far from providing more comprehensive c.are, provides merely fragmented care and a dilut'?n of personal responsibility. Despite the lavish Sifts which the physical sciences have given to ^edicine, medical care, in the sense of the professional handling of a total illness situation in the '^dividual, is essentially a person to person rela-
doctor
tionship. a
The patient
cannot have a
team, however well
however well led. Having said so
organised
relationship
that team and
much it should be added that is one area in which a team can be of enormous value. I refer to the field of family medicine ar*d to the paradoxical position of the family doc*?r- As a family doctor, the general practitioner has a Unique access to the structure of the family unit, hile he may derive all sorts of added insights
*here
comin 7
from this knowledge, the fact that he stands in absolutely similar professional relationship to perhaps three generations of a family involves him in a conflict of loyalties no less serious than those which lawyers are at such pains to avoid. For example, if he is able to help a daughter to tear herself free from a dominating mother, how can he deal with the mother's misery, and the pain which the daughter's behaviour will inflict upon her?
High
drama
A bright
10-year-old schoolboy suddenly
devel-
oped severe epileptic seizures. Three months later his sister, attending a grammar school, was admitted to hospital in coma. She recovered rapidly and detailed investigation revealed nothing amiss. She was discharged home, but the episodes recurred and each time she was rushed to the hospital for lumbar puncture. During all this high drama her mother showed only a minimal interest in what was going on, and for weeks her father made no effort to discuss the problem with any of the doctors involved. Slowly, the outlines of the problem became discernible: the 14-year-old girl was already physically a woman and her mother was struggling to keep her a child, the father was reacting violently to her awakening sexuality. The boy's epileptic fits not only occasioned all sorts of frightening fantasies in the girl, but cemented the family feeling of secrecy and shame. If the doctor is to work with any one of the 'parties' to this kind of situation?and the legal term is appropriate?there has to be a heightening of the doctor/patient relationship. The exclusive nature of this alliance between the doctor and the patient is often expressed by the patient either as a shutting out of the rest of the family ('Mum just can't understand how I feel') or as a shutting out of the rest of the medical profession ('I tried to talk to the specialist about all this, but he wouldn't listen to me').
Watching brief In this case I referred the boy to a consultant with an interest in epilepsy. We decided that the consultant would deal with the boy, that his P.S.W. would try to take on the mother, that I would continue to treat the girl, and that we would all keep a watching brief on the father, whom we all felt was the key to the situation. The details of the treatment and of its successful outcome are not relevant here: what is relevant is the
psychiatrist
demonstration of meaningful teamwork. Each of us adopted a therapeutic role to a whole patient. Had we, instead, applied ourselves, the psychiatrist to his notion of the psyche of each member of the family, the P.S.W. to her notion of the psycho-social milieu of the family, and myself to some vague abstraction of general care?and this is usually what is meant by teamwork?the result might have been very different. What help can the general practitioner expect from the mental health services? Specifically, what can his expectations be of the consultant psychiatrist, and when should he refer to him? It is easier to define those cases where referral is absolutely indicated. In the classical psychoses, neuroses, and mental subnormality, the relationship between the psychiatrist and the general practitioner is quite clear-cut. Having said this, one must add that these cases form a very small minority of the mental health problems with which the general practitioner deals. Personal dilemmas of his problems, however, the has little to offer the general practitioner. The anxious patient, the unhappy patient whose personal dilemmas have boiled over into an illness, for the most part receives little of material value from a consultation. Does it really help the general practitioner when the psychiatrist reformulates for him the problem that he calls 'John Smith', as 'inadequate personality with anxiety and phobic symptoms'? Apart from a few honourable exceptions, the patient's follow up consists of a juggling with tranquillisers and anti-depressants and so-called supportive psychotherapy. That is, a therapy that is hardly ever supportive and certainly never psychotherapy. It may be a hard thing to say, but perhaps the most valuable part of a psychiatric referral is the long waiting list in the outpatient department?it is so much better, both for the general practitioner and his patient, to travel hopefully than to arrive at the reality. The reason for this unhappy state of affairs is not that psychiatrists are failing to do their job, but rather that both the general practitioner and the psychiatrist have failed to agree about the nature of psychiatry. If, however hard we look for it, we are unable to determine the proper frontier of psychiatry, it is only because the frontier is a medical no-man's land between conflicting theories and attitudes. Here we come to the nub of so many of our problems: to the explanation of the vastly different levels of psychiatric illness reported from general practice; to the blurring of therapeutic roles and the failure of teamwork; to the breakWith the
psychiatrist
majority
down of the dialogue between the general practi' tioner and the consultant psychiatrist. The handling of a schizophrenic crisis is clearly the speciality of the psychiatrist. The handling of a backache clearly that of the general practitioner. But as we have seen, the illness that is labelled 'backache may have other portents. Is this situation illness or mental illness? Is it a psychiatric prob' lem? The Cartesian notion of man as a ghost in 3 machine will not work for general practice. We have had to learn to think in terms of whole-person pathology, and even concepts like 'psychosomatic disease' have a limited usefulness once we come to see that all illness has a symbolic meaning, and that this symbolic meaning may be more important than its 'scientific' description. If we can accept this, if we can deal with the whole person, we shall restrict our referrals to the psychiatrist to those cases of classical psychiatric illness which he has been trained to recognise and deal with, and cease to use the psychiatric referral as a means of rejecting a patient whose illness situation will not fit into the diagnostic strait-jackets that we were taught at our medical school to recognise as propef illness.
physical
Conforming society I started
by saying that the general practitioner increasing amount of mental ill-health. It is impossible to say exactly what this may mean-
sees an
but I suspect the statement contains a number of truths. Despite the seeming liberalisation of society, the mass media have made us a more conforming society than ever before. The less permissive the society, the greater the strain on those who deviate from the norm?what has been called 'the psychosis of the consensus'. But we are also becoming more sophisticated. The result of penicillin, modern surgery, and the stupendous advances in public health, is a patient whose expectations about the quality of life are infinitely higher than ever before. The woman who a generation or two ago was succumbing to the chronic disease of repeated childbirth, will come to her doctor today because she cannot achieve an orgasm or because she has become short-tempered with her baby. She may bring the problem openly, and often today she does, or she may bring it wrapped up in the tradi' tional parcel of physical complaints that her doctor has been led to expect. If the general practitioner is seeing more mental ill-health, it is because he is coming face to face with his patients' greater expectation of human happiness. Far from being the sign of a sickening society, this may well be the sign of a sane society in the process of reexamining its values and its needs.
