Table Of Content2042 Prelims 5/6/00 11:28 AM Page i
What Are You
Feeling, Doctor?
Identifying and avoiding defensive
patterns in the consultation
John Salinsky
and
Paul Sackin
Foreword by
Dame Lesley Southgate
Professor of Primary Care and Medical Education,
Royal Free and University College Medical School, London
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© 2000 John Salinsky and Paul Sackin
Radcliffe Medical Press Ltd
18 Marcham Road, Abingdon, Oxon OX14 1AA
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise without the prior permission
of the copyright owner.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
Reprinted 2007
ISBN 13: 978 1 85775 407 0
Typeset by Action Publishing Technology, Gloucester
Printed and bound by TJI Digital, Padstow, Cornwall
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Contents
Foreword vii
Preface ix
About the authors xii
Acknowledgements xiii
Group leader’s preface xv
Michael Courtenay
1 Morning surgery 1
2 Setting the scene 7
References 12
3 Some doctors and their defences 15
The disintegrating hearing aid 15
‘I’d like some sleeping tablets’ 19
A lump in the breast 23
The ‘personal self’ and the ‘professional self’ 25
References 28
4 The work of the group 29
References 35
5 The group works on the cases: threats to the doctor 37
Michael Courtenay
Diagnostic confusion 38
Threats to the personal self 42
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iv What are you feeling, doctor?
Challenge to the ‘apostolic function’ 46
Sylvia: three missing days 50
6 The personal factor 57
The case of the dapper accountant 57
An echo of betrayal 64
A middle-aged couple 67
Conclusions 72
7 How the group reflected on the cases: metaphors and
models 75
Marie Campkin
Games people play 76
Responses and reflexes 79
Group defences and parrot jokes 81
References 84
8 Patterns of avoidance: the variety of defensive
behaviours 85
Michael Courtenay
9 Predisposing factors 95
Practice policies 95
The dumping syndrome 98
Keeping a distance 101
Reference 102
10 The time problem 103
External time pressures in the NHS 104
Does ‘triage’ help? 106
Patients who make doctors look anxiously at the clock 108
Strategies for managing time 110
Conclusion 112
References 112
11 What are you feeling, doctor? Group members reflect
on their experience 113
John Salinsky
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Contents v
Doing the research: collecting and assessing data 115
The background: the group and its members 116
What did I want to find out? 116
The starter questions 117
Results 118
Conclusions 124
References 125
12 What can doctors do? 127
Predisposing factors 128
Warning lights 128
Defensive strategies 130
Should all defences be abolished? 132
What can doctors do? 133
References 139
13 Implications for medical education 141
Case history 141
References 148
Appendix: ‘Some medical defences against involvement
with patients’ 1978 Michael Balint Memorial Lecture 151
Tom Main
Index 169
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Foreword
In the early 1970s I joined a Balint group. During the next 5 years,
a period of full-time busy general practice for me, I began to make
sense of the consultation. But the greatest benefit came from
hearing the stories of doctor–patient relationships recounted by
other group members. They brought my own relationships with
patients into sharp, and sometimes uncomfortable, focus. I can
recall those sessions very clearly 25 years later and in particular
my private learning about my own defences. Those lessons had to
be learned over and over again, as consultations apparently
straightforward became unpredictable and dysfunctional.
Communication between patients and doctors is analysed,
debated and assessed in modern general practice more than ever
before. Assessment of video-taped consultations is mandatory
before a doctor can commence independent practice in the UK. In
the USA there is a formal requirement to evaluate the humanistic
behaviour of internal medicine residents, including the qualities of
integrity, respect and compassion. But although the expectations
of doctors’ behaviour are explicit, things can still go wrong.
Sometimes the doctor’s feelings get in the way.
In this book the work of a traditional Balint group is extended
beyond its previous boundaries. Starting from the patient’s story
and the recounting of the doctor–patient relationship, the reader is
allowed to meet the personal self of the doctor. The feelings and
defences of the doctor are explored. General practitioners will
recognise the authenticity of the work of the group. Others will
gain more understanding of the apparently perverse behaviour of
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viii What are you feeling, doctor?
some doctors with some patients. But the analytical part of the
book takes us beyond description on to analysis and reflection
about what might be done. The implications for future research
and reforms in medical education are considerable. This work for
the future will also mark the joining together of the Balint group
method with approaches such as evidence-based medicine and the
assessment of clinical competence. The missing pieces about the
failure of some doctors to incorporate best practice into the consul-
tation may be addressed by paying attention to what the doctor is
feeling rather than what he/she knows.
Professor Dame Lesley Southgate
May 2000
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Preface
Although family doctors are now trained in communication skills
and encouraged to study their interactions with their patients on
video, there are still too many consultations which leave both
doctor and patient feeling troubled. This is likely to occur when
the patient arouses disturbing feelings in the doctor which are not
recognised or understood. Unable to cope with these feelings,
doctors often develop powerful defence mechanisms to protect
themselves. Some defences are essential if the doctor is to survive
and to continue to function professionally. But excessive and
unnecessary defences simply prevent him from listening with
empathy. In this situation the doctor knows perfectly well what to
do to achieve a successful consultation, but finds himself unable to
do it because he can no longer ‘tune in’ to the patient’s feelings.
This book is based on the work of a group of general practition-
ers who met regularly over a 5-year period to explore the
defensive over-reactions and failures of empathy which they
noted in their everyday consultations. The process of working was
based on the well-known ‘Balint’ method of case discussion. This
was originally developed by Michael Balint, a psychiatrist and
psychoanalyst who worked with groups of general practitioners in
London in the 1950s and 1960s to study the dynamics of doctor–
patient relationships.
Our group consisted of ten experienced general practitioners,
two of whom acted as group leaders or facilitators. The group
members presented case histories in which they had felt confused,
disturbed or upset either during or after the consultation. After
