The opaque consultation, an illustration of the Doctor as Drug

Talk Code: 
Chris Clark
Author institutions: 
University of Exeter

I have been a member of a small GP group throughout my general practice career. Each year we took two days away, often at the old Atlantic Hotel Polzeath, to reflect on and refresh our practice and ourselves. Around the Millennium we worked with a writer; one brief on the day was to write a short piece describing an encounter at work. My response was the dialogue presented, intended at the time to light heartedly paraphrase one, or a few, of my recent confusing encounters. I was trying to capture occasions when a consultation has a seemingly comprehensible beginning and end, but one is left feeling unsure as to what has taken place, and what use one has been to the patient – a nagging feeling that things could have gone better.   

Consultations addressing vague or unexplained symptoms can be challenging. After many years of hindsight I now reflect on this piece as a metaphor for “the doctor as drug”. Balint introduced this concept in his seminal 1957 book, illustrating the concept that doctors unconsciously as well as consciously deliver psychotherapeutic benefit to their patients within the consultation. Although much criticised since, the recognition of this psychosocial component remains essential to current practice. A non-judgmental and empathetic approach is a pre-requisite to transactions at this level, as illustrated by Carl Rogers’ definition of “unconditional positive regard”. Ballatt and Campling have built on this, comprehensively summarising how kindness can facilitate, and indeed is essential to, effective dialogue with both patients and colleagues.   

But do these consultations do any good? The doctor’s feelings arguably don’t matter if the patient has left feeling better. Dowrick, in his Helen Lester Memorial Lecture to this Society in 2016, wonderfully illustrated the longer term positive outcomes of remaining engaged with individuals, at times quite troubled, whose individual consultations appeared at the time to be accruing no discernible benefit. Continuity of care itself, as exemplified in that lecture, has also been associated with a wider range of benefits including reduced mortality rates.   

So the doctor’s perception of success or otherwise in the consultation must remain the doctor’s, but not necessarily the patient’s, concern. I originally titled this piece “Can we start again?”. I no longer feel that such consultations need to be revised, and now fully recognise the unconscious and empathic elements of such an encounter. However expressions of gratitude for what can feel, at best, an adequate consultation continue to remind me of the privileged position that we occupy as general practitioners. We are, to coin Berger’s words, fortunate indeed.