Te a c h in g old Docs New Tricks
You are a general practi.tioner in your mid Jorti,es and haue been in practi,ce Jor fifteen years in a rural area oJ South Africa. You haae attended solne congresEes but the work load of your practi,ce and bringing up your family haue left you with q, need to upd,a,te Aour knowledge. You decide to sit one of the postgraduate efialns in Jami.ly medicine. You haue uritten the papers and now go for the oral eraminati,ons. The erami,ner erplains that a reuoluti,on has occurred in Jami,ly practice theory since you qualLfied and asks
gou the fol\owing question:
Question: Can Eou gi,ue me an erample of the way a "pati,ent-centred approach" has helped you and a patimt in your practice?
A n s w e r : Y o u ' v e a l w a y s f e l t t h i s p a t i e n t - centred care thing was a lot of academic clap- trap. You're a busy GP with a lot of clinical work to do and you feel you do not have the t i m e t o i n d u l g e i n t h e s e t h e o r e t i c a l i d e a s thought up by academics.
You decide in your wisdom that this may not be the time to express these feelings.
You do remember consultations in the past when you have "reached" the patient and had the satisfaction of knowing that you were about to cut them short but instead vou had
"allowed them in".
A black women of about 60 years of age came t o s e e y o u d u r i n g a b u s y c l i n i c . S h e complained of headaches, pain across her shoulders some epigastric pains and muscles p a i n s " a l l over the body, doctor". You had h e a r d t h i s c o m p l e x o f s y m p t o m s s o m a n y times before.
You went into your medical routine and found an obese, woman with slightly tender shoulder muscles, BP 140/90, normal respiratory and
cardiovascular systems and a stiffness of the spine.
You had followed the traditional routine of q u e s t i o n a n d a n s w e r t o r e a c h a m e d i c a l diagnosis of osteoarthritis and were reaching f o r t h e p r e s c r i p t i o n p a d t o p r e s c r i b e anti- inflammatories and analgesics.
You were about to end the encounter at this point. You had followed your medical agenda and the waiting room was full.
But on this occasion you had opened up the consultation after she had said that "life is very difficult these days". Usually you reply
" y e s , it is, isn't it" and carry on in a rush towards the diagnosis. This time you "allowed her in" by replying in an open or facilitating way.
She explained that she was a teacher with five children and had been divorced for six years.
She was the wage owner and had brought all h e r c h i l d r e n u p h e r s e l f a n d h a d n o w to support her husband, who had returned as a drunkard.
Suddenly this had changed from "another case o f o s t e o a r t h r i t i s " i n t o a c o m m u n i c a t i n g doctor-patient relationship.
Question: And hou did it help you and the patient?
Answer: You explain how this helped both you and the patient.
Question: Do you belieae that listening and doi,ng nothi,ng can sometimes be enough i,n an, encounter ui,th a patient?
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Answer: You have often felt in your practice that you are "forced" to give treatment or a prescription' T h e p a t i e n t o f t e n r e q u e s t s i t a n d m o d e r n technological society expects you to "do something"
or "prescribe something"'
Some benefits of giving no treatment are:
1. It protects the patient from iatrogenic harm.
2. It saves the patient and doctor from wasting time, effort and moneY.
3. It delays treatment until a more appropriate time' 4. It provides the patient with an opportunity to
discover that he can do without treatment.
5 . I t a v o i d s a s e m b l a n c e o f t r e a t m e n t w h e n n o effective treatment exists.
Reference:
F r a n c e s A , C l a r k i n J F . N o t r e a t m e n t a s t h e p r e s c r i p t i o n o f c h o i c e ' A r c h i v e s o f G e n e r a l Psychiatry l98l;38:5 42-5 45.
On this theme see also:
"The doctor as drug" (Balint, 1964, in references)
" W h e n l i s t e n i n g i s e n o u g h " ( C a s s e l l E J . T h e healers's art. A new approach to the doctor- patient relationship. Philadelphia: J B Lippincott Co, 1976.)
V i s m e d i c a t r i x n a t u r a e " T h e h e a l i n g p o w e r o f nature" (Cousins N. The anatomy of an illness as perceived by the patient. New York: W W Norton and Co, 1979.)
"The myth of Cure" (Talmon, 1990, p.123)
Next lssues are :
December 1994 EPilePsY January 1995 DePression February 1995 GastroenterologY March 1995 Doctor-Patient
RelationshiP April 1995 Prevention/Screening May 1995 Backache
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