Who Listens to the Doctor? Part 2

Doctors are trained to solve problems and to fix things. For much of what we do, this is an appropriate and helpful strategy. But for primary care doctors on the front lines with developing children and families, another strategy is needed. In a previous post, I wrote about an experience I had teaching young doctors in training. One intern proclaimed to another at the beginning of my talk that she would sleep through it. Instead, she was an active participant when she saw it was an opportunity to unburden herself of a difficult and painful interaction with the mother of a young boy.

This discussion I had with those young doctors made me think of a wonderful book by a Hungarian psychoanalyst, Michael Balint, called The Doctor,his Patient and the Illness. Following World War II, general practitioners in England found that much of their medical practice was consumed by addressing complex psychological problems. Out of this phenomenon there grew a research seminar to study psychological issues as they present in general medical practice. These later became know as “Balint Groups”, and consisted of a group of primary care doctors and a psychiatrist who facilitated the discussion. In the introduction to this book, in which Balint describes in detail the proceedings of his seminar, he writes:

The first topic chosen for discussion at one of these seminars happened to be the drugs usually prescribed by practitioners. The discussion quickly revealed- certainly not for the first time in the history of medicine-that by far the most frequently used drug in general practice was the doctor himself, i.e. that it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient-in fact, the whole atmosphere in which the drug was given and taken.

This seemed to us at the time a very elevating discovery, and we all felt very proud and important about it. The seminar, however, soon went on to discover that no pharmacology of this important drug exists yet. To put this discovery in terms familiar to doctors, no guidance whatever is contained in any textbook as to the dosage in which the doctor should prescribe himself, in what form, how frequently, what his curative and maintenance dose should be, and so on….in fact, the paucity of information about this most frequently used drug is appalling and frightening.

Balint groups are now part of many family practice training programs in the United States. The idea is similar to Balint’s original concern, namely to address directly the way in which a doctor, as a person with a relationship with a patient, is a critical part of the treatment. Offering oneself in this way can take its toll, particularly if a doctor is very good at it. The groups provide an opportunity to address not only the treatment of the patient, but also what it is like for the doctor when many troubled people unburden themselves of their deepest feelings. In many training programs for mental health professionals there are opportunities to talk with others about these experiences, in a sense allowing the clinician to unburden him or herself and therefore be open to listening to his or her patients. But for primary care doctors such an experience is the exception, not the rule.

As health care reform moves forward, finding a way to attract doctors in training to primary care will be critical. Appropriate financial compensation is essential. Understanding and respecting the "doctor as drug" concept is equally important in building a system that promotes a model of prevention.

What I Learned From Eli

Yesterday my 11 year old son ate his first oyster. "I slurped it down," he said."It was chewy and tasted of lemon." I asked him if it was OK for me to write a blog post about him. "Sure," he replied. He is proud of his role as my teacher.

For the first seven or so years of his life, after breast milk and baby food, Eli ate only three things- bagels with cream cheese, pasta with pesto and chicken nuggets. My mother-in-law, though not one to judge me, looked askance when we arrived at her house with our own Tupperware containers of food for him.

Once I read that picky eaters have more taste buds than the average person. I believe that must be true. It always seemed to us that things just tasted more to Eli. It wasn't that he was being oppositional or controlling. He simply could not eat other foods. Similarly, he couldn't stand loud noises. Once, on a family outing to hear fireworks, he and I had to go back to the car and watch from the muffled safety inside. Now Eli is an accomplished musician who plays guitar and saxophone.

Things were not easy for him or us in those early years. But amidst all the advice and worry, one wise very good friend said to me, "Be careful." I understood this to mean that we should not be pushed into doing things that did not feel right to us. That we needed to hang in there with him. So we did.

He still has his moments. The second oyster made him gag, and he declared, "I'm never eating another oyster for the rest of my life." But he ate one. And for him that was quite an accomplishment.

Letter in NY Times refutes Warner's book

OK- Just one more. Here is a letter published in today's New York Times Science section. The 150 word limit helped me present a clear and concise argument!


To the Editor:

Re “Doing an About-Face on ‘Overmedicated’ Children” (Books, Feb. 23): The myth of the overmedicated child is no myth. The morning of the day Judith Warner’s book came out, in my pediatric practice I saw three children for refills of their medication for ADHD. One’s mother was an actively drinking alcoholic. Another’s father had recently been deported. A third told me of chaotic scenes of yelling among siblings and parents.

None of these issues were being addressed. Our culture’s condoning of use of medication to treat complex problems merges with parental resistance and lack of access to quality therapy to create this situation. Certainly medication may protect the brain. But being understood by the people who love you can also protect the brain. Over-reliance on medication leads our culture to shirk responsibility for listening to both parents and children.

Claudia M. Gold, M.D.

Great Barrington, Mass.