Family practice: A comprehensive medical approach

Family Practice: A Comprehensive Medical Approach B y DoN D.

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E S P I T E M E D I C A L S C H O O L S n e w l y opened,, meal.teal s c h o o l s in the stage of b u i l d i n g , a n d m e d i c a l schools p l a n n e d for tl~e F,~t'Jre, it appears, a c c o r d i n g to the.Assistant Secretary of I l e a l t h , E d u c a t i o n and ~V(,tfare,.Dr. Phil-. lip B. Lee, that there will not b e a relative increase" in the r a m , h e r of doctors p e r capita in the U n i t e d States, at least for the next t~n years. A l t h o u g h there is c o n s i d e r a b l e interest in s t r e a m l i n i n g the practice of medicine to allow the doctor the major portion of his time for clinical work, a n d although the a e r o s p a c e i n d u s t r y has m a n y sophisticated ideas and technixlues to offer, e s p e c i a l l y in the area of i n f o r m a t i o n - g a t h e r i n g a n d retrieval, the prospect of i m p o r t a n t teehnologiea] c h a n g e s is not rosy. This is for the s i m p l e reason that as our m e t h o d s of s p e e d i n g th'e a v a i l a b i l i t y of i n f o r m a t i o n increases, so does the a m o u n t of i n f o r m a t i o n a v a i l a b l e to physicians. T h i s is.not only obvious in the n u m b e r s of m e d i c a l journals, or in figures that i n d i c a t e a 300 p e r cent increase in words written a b o u t m e d i c i n e in the past .tell years, b u t in the very fact that m o r e and m o r e g a d g e t s and testing devices are b e i n g i n v e n t e d w h i c h r e q u i r e great skill and, of course, time on the p a r t of the p h y s i c i a n s to utilize. Thus, it seems u n l i k e l y that tile p h y s i c i a n in the foreseeaMe future will h a v e the luxury of "treating the w h o l e patient," with the c o n c o m i t a n t i m p l i c a t i o n that he .will h a v e the time, encrg9,, a n d interest to listen to patients" sexual a n d psychological p r o b l e m s as well as to the tales in his chest. O n e possible bit of silver in the o t h e ~ y i s e g r e y i n g m e d i c a l cloud is thai /he g e n e r a l p r a c t i t i o n e r will b e more a n d m o r e freed from the s p e c i a l l y technical aspects of m e d i c i n e b y a n i n c r e a s e . i n the ut~mber of specialists, a n d t h a t tile logistical p r o b l e m s w h i c h n o w r e q u i r e in s o m e areas that he do major surgery, obstetrical complications, and other technical a n d t i m e - c o n s u m i n g aspects of m e d i c i n e m a y b e r e l i e v e d b y n e w d e v e l o p m e n t s , , such as p r o p o s e d m e d i c a l centers a n d the use of helicopters a n d other devices w h i c h will s p e e d the flow of reD" sick p a t i e n t s to areas w h e r e they m a y b e treated b y spizeialists. This m a y m e a n that the general p r a c t i t i o n e r can get b a c k to one of his most i m p o r t a n t functions, if not t h e most i m p o r t a n t ~ n a m e l y , h i s - p o s i t i o n as the p h y s i e i a n to the family. It has l~een m y experience, g a r n e r e d t h r o u g h visiting-several large m e d i c a l centers and m o d e r n m e d i c a l clinics, that med.ical"charts of the m e m b e r s of a f a m i l y are kept i n d i v i d u a l l y a n d are r e c o r d e d in the histor)- room o n l y - u n d e r an a l p h a b e t i c a l system as are all other individtlals," related or not, witt~ the s a m e last n a m e . E v e n if the memlx~rs in a fahlily s h o i d d all " h a v e the s a m e

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FA.-M[ILY P I t A C r I C E ;

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hatemist, he may h e too b u s y t o recall t h a t the o u t b r e a k of c e r t a i n disorders in the f a m i l y was suspiciously time-linked, and h i s r e c o r d s w i l l n o t h a v e b e e n w r i t t e n in sucli a w a y as to let h i m see at a "glance w h a t the m e d i c a l liistory of t h e f a m i l y is a n d has been. W e k n o w from the w o r k of ] t a g g e r t y in Butfalo ( a n d o t h e r s ) t h a t streptococcal infections h a v e bee'n s h o w n to b e more p r e v a l e n t in c e r t a i n f a m i l i e s on a basis t h a t c a n o n l y l:e re'asonably a c c o u n t e d for b y the stressful n a t u r e of the family's situation..~,'Ve k h o w f r o m the work of an E n g l i s h g e n e r a l p r a c t i t i o n e r , l t o b e r t Kellner, ~ t h a t o u t h r e a k s of certain disorders in families are n o t i c e a b l y q u i t e c o m m o n if o n e keeps ),early cards that reflect the Clinical visits of all f a m i l y m e m b e r s so t h a t t h e y m a y be v i e w e d at a glance. Kellner's simple, c l e a r system s h o u l d be r e a d by e v e r y g e n e r a l physician. T h e n a t u r e of f a m i l y i n t e r a c t i o n has b e e n s t u d i e d largely in the p a s t ten years in the U n i t e d States, a n d a l t h o u g l l the surface has only b e e n s c r a t c h e d , it is a l r e a d y clear t h a t family m e m b e r s t e n d to be involved with each o t h e r in q u i t e intensive ways a n d t h a t s i t u a t i o n s w h i c h m a r k e d l y affect one m e m b e r of the family, e i t h e r p h y s i c a l l y or e m o t i o n a l , or both, are apt t o h a v e r e v e r b e r a tions for o t h e r f a m i l y m e m b e r s . T h e idea of c o m p r e h e n s i v e f a m i l y m e d i c a l care involves a p o i n t of v i e w t h a t t h e physieiml will not h a v e " l e a r n e d in m e d i c a l school. T h e t r a d i t i o n a l u n i t for m e d i c a l t r e a t m e n t is one p a t i e n t a n d one physician. I t is difficult for t h e physician, without, h a v i n g h a d it especially called to his a t t e n t i o n , to t h i n k in terms of a f a m i l y u n i t in relation to m e d i c a l disorders. T h e f o l l o w i n g e x a m p l e is an idea of w h a t kind of a c h a n g e in viev,,point is involved. I well r e m e m b e r h o w m u c h I e n j o y e d H e n n a n n \Vouk's novel, The Caine Mutiny, w h e n it was first publkshed a few years after W o r l d \Var II. Latter, I saw the play, TI~e Caine AIutiny Coztrt alartial, with a fine B r o a d w a y east; mad t h e n a few years later, I saw H u m p h r e y Bogart as C a p t a i n Q u e e g in the m o v i e vers:on of Tlte Caine ,1Iutiny. t / e c e n t l y , I saw the m o v i e on T V a n d e n j o y e d it again almost as m u c h as on first vie',ving, y e t it s e e m e d in significant ways a different m o v i e from m y recollection. T h e c a u s a t i v e f a c t o r was a c h a n g e of v i e w p o i n t in me a n d not a n y hack of fidelity on the p a r t of t h e television p r e s e n t a t i o n . Originally, I h a d seen a m o v i e w i t h the m a i n action r e v o l v i n g a r o u n d Queeg's m e n t a l illness a n d t h e i n e v i t a b l e , yet disastrous action t h a t Steve, his executive oIfieer, h a d to take. O n e of t h e scenes that stood out lnost in m e m o ~ , was the Courtroom action w h e n Q d e e g , n e e d l e d by the clever d e f e n s e attorney, spilled his p a r a n o i d suspicions like vomitus u p o n the c o u r t r o o m floor; mad defense a n d p r o s e c u t i o n alike b e c a m e n a u s e a t e d , a n d l o o k e d a w a y as if the revolting mess m i g h t disa p p e a r . A l t h o u g h Queeg's b r e a k d o w n m o m e n t a r i l y a p p e a r s to be a b l o w for the ferees of good, it works out to b e a kind of Mexican standoff w h e r e neither C a p t a i n Q u e e g nor his executive officer is v i n d i c a t e d . Initially, I f o u n d this a d i s a p p o i n t i n g outcome, b v t I t h i n k I h a d not d o n e suflrlcient justice to ~ l r . 1,Vouk's brilliance. In seeing the m o v i e r e c e n t l y on television, the e m p h a s i s that took place in m y m i n d was e n t i r e l y different. W h a t I f o u n d myself noticing was the n a t u r e

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DON D. JACKSON

of the i n t e r a c t i o n b e t w e e n Q u e e g a n d his o/fleers. F o r e x a m p l e , h e b e r a t e s a sailor f o r i m p r o p e r uniform just a f t e r h a v i n g given the o r d e r to e x e c u t e h a r d r i g h t r u d d e r . T h e h e l m s m a n , a w a r e that t h e y will c o m e a b o u t full tilt a n d cut t h e i r ox~n tow lines, protests once a n d is told by Q u e e g to "'shut up." H e a n d his b u d d y at the w h e e l e x c h a n g e significant looks, s a y n o t h i n g f u r t h e r , a n d , of course, t h e inevitahle h a p e n s . N o t t h a t Q u e e g is a n y rose, m i n d you. H e c o n t r i b u t e s to a l l aspects of the i n c r e a s i n g l y difficult situation b y e v a s i o n , obfuscation, a n d distortion, b u t his officers let h i m flounder. It is obvious thlat a w a r s h i p , especially one not p a r t of a p a c k or floatilla, is a m o v a b l e island w h e r e t h e natives are f r e q u e n t l y p r e s e n t e d w i t h the p r o b l e m of either h a n g i n g t o g e t h e r or h a n g i n g s e p a r a t e l y . In this r e g a r d , t h e o f f i c e s of the USS C a i n e are n o t a b l e failures. V~qaen C a p t a i n Q u e e g calls a m e e t i n g of his officers following a second u n f o r t u n a t e experience, h e a t t e m p t s to explain t h a t he m e a n t well b u t m a y h a v e d o n e the w r o n g thing. F i e asks a n y of the officers w h o feel this to b e true to Speak up. N o one raises his voice, a n d the n e x t incident a p a r t i c u l a r l y m e a n bit of p i c a y u n e discipline b y Q u e e g follows thereafter. T h e m o r e t h a t Q u e e g is r e j e c t e d in his a t t e m p t s to " r e a c h " his officers, t h e firmer the wall of resistance a n d t h e m o r e Q u e e g b e c o m e s absurdly p u n i t i v e a n d thus increases the d i s t a n c e b e t w e e n h i m s e l f a n d his men. M e a n w h i l e , b e h i n d his back, his officers gossip a n d c o m p l a i n a n d feed the p a r a n o i d fires. -~Vhen one shifts f r o m Queeg, as an individual, to v i e w i n g the m o v i e as an i n t e r a c t i o n or c o m p a g e s t h a t exists b e t w e e n a g r o u p of m e n w i t h a c o m m o n p u r p o s e a n d p l a c e (like a f a m i l y ) , the view is v e r y different. This is the w a y a p h y s i c i a n s h o u l d r e g a r d patients c o m i n g f r o m the s a m e family. T h e r e are no good guys or b a d g u y s or long-suffering w i v e s a n d b a s t a r d l y h u s b a n d s . T h e r e a r e p a t t e r n s of i n t e r a c t i o n w h i c h h a v e to b e so c o n c e p t u a l i z e d that it isn't possible to s a y the h u s b a n d w i t h d r a w s b e c a u s e his w i f e nags, n o r the reverse. In changiaag to a f a m i l y point of view, one m i g h t look at s o m e t h i n g like coronary., attacks. Studies in r e c e n t years, especially by F r i e d m a n a n d his associates at Nit. Zion H o s p i t a l , h a v e i n d i c a t e d t h a t r e g a r d l e s s of o t h e r factors, such as b l o o d pressure, cholestrol levels, s m o k i n g , etc., t h e i n d i v i d u a l ' s personality a p p e a r s to b e p a r a m o u n t in d e t e r m i n i n g his c h a n c e s in h a v i n g a coronar)r occlusion, a n d especially a fatal one in his m i d - y e a r s . F r i e d m a n h a s s e p a r a t e d p a t i e n t s into t w o groups, g r o u p "A" a n d g r o u p "B." T h e f o r m e r are h a r d - d r i v i n g , a m b i t i o n - r i d d e n , executive types w h o often are assertive, a g g r e s sive, a n d a c c o m p l i s h a good deal. By contrast, the "'B" g r o u p are m o r e easygoing, even t h o u g h t h e y m a y l:e in a position of c o n s i d e r a b l e i m p o r t a n c e , b e c a u s e t h e v t e n d to d e l e g a t e a u t h o r i t y . In looking at it from a family i n t e r a e t i o n a l s t a n d p o i n t , it m i g h t be h y p o t h e sized ( a n d our limited cliaaical e x p e r i e n c e t e n d s to verify this) t h a t an individual of F r i e d m a n ' s "A'" t y p e r e q u i r e s r e i n f o r c e m e n t for his b e h a v i o r p a t t e r n s a n d t h a t such r e i n f o r c e m e n t usually c o m e s from his f a m i l y a n d his i m m e d i a t e s u r r o u n d i n g s . Thus, at the p l a n t the t y p e "B'" people m a y be u s i n g the t y p e "'A's" as s o m e o n e to w h o m they can d e l e g a t e a u t h o r i t y a n d k n o w it will b e c a r r i e d out. At home, the c o r o n a r y - p r o n e individual m a y b e c o n s i d e r e d b y

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f a m i l y m e m b e r s as t h e m a i n " m o v e r " or "'power" in the f a m i l y w h e t h e r it relates to f i n a n c e s , d i s c i p l i n a ~ , action, social activities, or r¢/~hatevcr. F a m i l y responsibilities, de~isions, a n d so on, are often p a s s e d on to this i n d i v i d u a l w h o considers it his d u t y to a c c e p t the responsibility. O t h e r f a m i l y m e m b e r s m a y be thus d r i v i n g the c o r o l m r y p a t i e n t to his d o o m ( c o m p l e t e l y u n w i t t i n g l y ) , b e c a u s e the), e i t h e r will n o t o r c a n n o t take over themselves, a n d also 12ecause t h e y s i m p l y d o n ' t r e c o g n i z e t h e f a m i l y p a t t e r n . T h e y assume ( a n d t h e physic i a n m a y also) t h a t "'A" is s i m p l y a d r i v e r a n d that's the w a y it has t o b e . . As an illustration, I was r e c e n t l y t a l k i n g to a m o t h e r a n d f a t h e r w h o h a d b r o u g h t their son in b e c a u s e he was h a v i n g school difficulties. T h e p a r e n t s initially h a d d e c l a r e d t h a t t h e y h a d no p r o b l e m s at all, b u t w h e n t h e m a r r i a g e was e x a m i n e d , t h e y b e g a n to see t h a t t h e r e was c o n s i d e r a b l e covert-dissatisfaction t~etween t h e m . W h e n we t u r n e d to t h e q u e s t i o n of the father's w o r k ( h e "~vas a q u i t e successful e x e c u t i v e ) , he told m e h e was a n n o y e d t h a t p a r t i c u l a r e v e n i n g b e c a u s e h e t h o u g h t he h a d b o t c h e d a job t h a t he h a d b e e n s u p e r v i s i n g o v e r the p a s t several days. I a s k e d his w i f e w h a t she t h o u g h t of this ~.md she said it was very unlikely, t h a t he was such a c a p a b l e w o r k e r she d o u b t e d if he c o u l d possibly rnake a n y mistakes in his work. H e r h u s b a n d smiled, l o o k e d s l i g h t l y pleased, a n d did n o t r e m a r k a b o u t his wife's s t a t e m e n t . W h e n I c a l l e d his a t t e n t i o l l to it, h e still s e e m e d puzzled, a n d I told him t h a t a n y o n e w h o t h o u g h t I was p e r f e c t m a d e m e nervous. 1 asked him if lie h a d ever c o n s i d e r e d w h a t an e n o r m o u s r e s p o n s i b i l i t y it was to h a v e his wife t h i n k t h a t he c o u l d m a k e no mistakes in his joh, a n d h o w possible did t h a t m a k e it for h i m to go h o m e a n d feel o p e n l y d e p r e s s e d , c o n c e r n e d , or w h a t e v e r ? This s t r u c k h i m as a novel idea, a n d w i t h i n a few m i n u t e s he ,,,,,an c o r r o b o r a t i n g m y o b s e r v a t i o n by r e c o u n t i n g i n s t a n c e s of this kind of i n t e r a c t i o n as far back as their c o u r t s h i p . N a t u r a l l y , the wife felt I was p i c k i n g on h e r until it h e c a m e clear t h a t she often felt useless a n d " s t u p i d " b e c a u s e slat: h a d so little d e c i s i o n - m a k i n g p o w e r . It w o u l d be foolish for the family p h y s i c i a n to simply tell a t y p e "'A" c o r o n a r y risk to slow d o w n . Such a d v i c e is worse than useless bec.'tuse t h e p h y s i c i a n feels he has d i s c h a r g e d his d u t y , b u t it has doubtless g o n e t h r o u g h t h e p a t i e n t ' s ears w i t h o u t s c r a t c h i n g his brain. )If it has registered, even slightly, it "will soon be f o r g o t t e n once t y p e "'A'" gets back in his usual milieu with t h e significant others in his f a m i l y a n d t h e y put h i m in charge again. .SO.'~IE T I l E O I 1 E T I C A L AND P I ~ A C T I C A L C O * ' S I D E R A T I O N S

T h e b u s y f a m i l y p h y s i c i a n will w a n t to k n o w of w h a t use it is to h i m to b e c o m e "'family oriented.'" This is a p e r t i n e n t q u e s t i o n h e c a u s e h e is b e i n g a s k e d to c h a n g e his usual p o i n t of view a n d if, for example, h e ix a n internist, it m a y m e a n g e t t i n g i n f o r m a t i o n from t h e p e d i a t r i c i a n hi ord~t;r to k e e p some k i n d of f a m i l y records. T h e r e are two c o n s i d e r a t i o n s that are o f i m p o r t a n c e . O n e is the t h e o r e t i c a l p o i n t of view or the research d a t a t h a t m a y be collected from h a v i n g m o r e i n f o r m a t i o n , even of an a c t u a r i a l type, a b o u t families a n d illnesses; a n d t h e o t h e r is the practical c o n s i d e r a t i o n s that m a y e m e r g e from the I)hysieians t)eing f a m i l y o r i e n t e d . W e h a v e r e c e n t l y c o m p l e t e d at the M e n t a l l{esearch I n s t i t u t e a pilot s t u d y

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DON D. J A C K S O N

of a g r o u p of families, each of w h o m ])ave a child w i t h ulcerative colitis. T h e s e families seem to h a v e an overall restrictiveness ill t h e i r interactional p a t t e r n s with c o n s e q u e n t restrictedness oil the p a r t of the family, a n d tile individual m e m b e r s could be called "restricted" individuals. T h a t is, tlle families s e e m to e n g a g e in limited b e h a v i o r s b e t w e e n f a m i l y m e m h e r s a n d w e r e r e s t r i c t e d sociaUy as f a r as utilizing the c o n t i n g e n c y possibilities that the culture m a d e available. T h e r e w a s also overt evidence of restrictiveness in t h a t one m e m b e r w o u l d monitor tile b e h a v i o r of a n o t h e r a n d limit the other's b e h a v i o r to a v e r y n a r r o w range. If an individual in tile f a m i l y e n g a g e d in outside activities o t h e r than those p r e s c r i b e d b y law a n d custom (such as school or chl~reh), the family m i g h t take it as e v i d e n c e that t h e r e was an a v o i d a n c e of o l h e r f a m i l y m e m b e r s a n d this b e h a v i o r w o u l d be s t o p p e d . In fact, it m i g h t be s t o p p e d before it s t a r t e d b y t h e fact that the family w o u l d kill an i d e a p r o p o s e d b y a m e m b e r w h i c h w o u l d involve him outside of the family. T h e families s e e m e d to h a v e a rule a g a i n s t c h a n g i n g rules, a n d h e n c e virtually a n y n e w c o n t i n g e n c y possibility w a s t r e a t e d in m u c h the s a m e w a y . T h e r e was thus an inabilit)., to h a n d l e novel situations or to enjoy novel a n d / o r creative acts t o g e t h e r . Vehen p r e s e n t e d with s t i m u l u s ' m a t e r i a l , to w h i c h a large variety of possible responses could occur, the restricted f a m i l y w o u l d usually settle tile m a t t e r quickly a n d u n i m a g i n a t i v e l y , or t h e y w o u l d allow one m e m b e r (often the f a t h e r ) to settle the m a t t e r quickly b y edict. T h e s e families w e r e q u i t e different than a large g r o u p of "ordinary'" families w e h a v e b e e n s t u d y i n g at the M e n t a l R e s e a r c h I n s t i t u t e since M a r e h of 1959. In these families, there is i n v o l v e m e n t in a w i d e r a n g e of activities, even if it is at a cost to o t h e r f a m i l y m e m b e r s . H e n c e , ff f a t h e r a n d son go d u c k h u n t i n g a n d leave the w o m e n at home, the w o m e n will not l i k e it b u t t h e y will not d e p r i v e tile m e n of t h i s o p p o r t u n i t y a n d will a s s u m e that t h e y will be r e w a r d e d in time, or t h a t t h e y will e n g a g e in some special activity of their own. In o r d i n a r y families t h e r e a p p e a r e d to be m u c h l a r g e r e x c h a n g e s of s p o n t a n e o u s b e h a v i o r , such as l a u g h t e r , critical c o m m e n t s , sarcasm, irony, etc., o c c u r r i n g in a n o n r e g u l a r i z e d w a y . In looking at t h e d a t a f r o m our o t h e r family studies a n d f r o m the literature, it w o u l d a p p e a r that the c o n c e p t of a restricted f a m i l y m a y be useful in m o r e t h a n just t h e u l c e r a t i v e colitis group. F o r example, it is possible to p o s t u l a t e t h a t there should be six types of i l l n e s s ~ m e d i e a l c a r e p a t t e n ~ s ~ t h a t w o u l d b e r e v e a l e d b y h a v i n g d a t a a b o u t the entire family. (1) F a m i l y m e m b e r s h a v e ]reque.nt illnesses but rarely consult physicians. T h e y are so restricted socially t h a t t h e y do not e n t e r into the "'social act" of calling a p h y s i c i a n b u t treat illness as a f a m i l y affair, a n d b e i n g ill m a y h a v e m o r e t h a n a "'physical illness'" m e a n i n g within the family group. F o r example, illness m a y help restrict o t h e r f a m i l y m e m b e r s b e c a u s e of the sick one's n e e d for t h e m a n d f r e q u e n t illnesses will h e l p the f a m i l y stay restricted. (2) T h e r e w o u l d be families w h o h a v e rare illnesses but ]requent medical consultation, a n d these w o u l d c o r r e s p o n d to a restricted f a m i l y w h o follow a p a t t e r n of h y p o c h o n d r i a , d i s p l a y i n g a high d e g r e e of interest in m e d i c a l matters, in the use of r e m e d i e s which are nonspecific, and w h o w o u l d t e n d to use the subject of illness as a f r e q u e n t topic for family interaction. T h e i r social restriction w o u l d I)e aided b y fear of illness,

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w h e t h e r actual phobias, worries, or concerns such as not going skiing b e c a u s e one might b r e a k a leg. T h e o t h e r four tyl?es o f families do not sulfer from a distortion ot: the ration b e t w e e n f r e q u e n c y of illness a n d medical consultation b u t suffer instead from the restrictions i m p o s e d 1~), illness p a t t e r n itseIf.~For example, ( 3 ) t h e family has freqt~e{lt illnesses al~d'lrequent medical consultations b u t w i t h o u t exhibiting restrictiveness, a n d the illnesses arc usually genetic, constitutional, or occupational. Such families are logically restricted b y t h e i r ill health, b u t b e c a u s e of geneties, ignorance, socioeconomic reasons, etc., they c a n n o t do a n y t h i n g to c h a n g e the ~,llness p a t t e r n . (4) Frequent ill~esses plus frequeJtt consultation tcithout chronic organic illness: P"amilies with a p r e d o m i n a n c e of so-called p s y c h o s o m a t i c disorders w h e r e there is a high d e g r e e of eorrelatio~ b e t w e e n the course of the illness a n d interfamily contingencies. H e r e t h e physician w o u l d expect o u t b r e a k s of f a m i l y illnesses d u r i n g times of stress. H e w o u l d be g u i d e d in diagnosis a n d t r e a t m e n t b y p a s t experience with their pattens. (5) A f a m i l y ms,, h a v e rare ill*~esses and rare Inedical col~sultatio~ y e t not a p p e a r restricted since t h e r e was n e i t h e r excessive delay nor u r g e n c y in the s e e k i n g of medical care. T h e c h a n g e - o f roles within the family in o r d e r to cope with illness are easily, m a n a g e d a n d a c c e p t e d by tim patient w i t h o u t r e s e n t m e n t . This, obviouslv, w o u l d 1)e the ideal f a m i l y for the physician to h a v e in his care a n d one w h e r e he w o u l d take seriously a n y complaints, since his past experieuce of knowil~g the f a m i l y did not.-tend to use illness as a major m e a n s of c o m m u n i c a t i o n w o u l d tell him "'this illness is p r o b a b l y organic." ( 6 ) T h e family m i g h t h a v e rare illnesses a~d rare consultations but the family w o u l d b e a severely restricted one, a n d a l t h o u g h t h e illness was not used within the family as tools f o r c o m m u n i c a t i o n , the heavily o v e r s t r u e t u r e d p a t t e r n of interaction within t h e family w o u l d b e c o m e terribly chaotic w h e n a serious illness struck one mcm/)er, and the physician w o t d d be p r e s e n t e d with "'over-reaction.'" H e r e he w o u l d recognize the u r g e n c y of the situation a n d the n e e d for takitlg strong m e a s u r e s to quickly b r i n g m a t t e r s trader control a n d to heal the sick one as soon as possible a n d r e a s s u r e the other membei's, within reason. It is possible t h a t some such classification ( a l t h o u g h this is obviously a c r u d e one) a n d its use in developil~g a t y p o l o g y o f families w o u l d provide as m u c h information for the p h y s i c i a n as we n o w h a v e from noting merely g e n e t i c t e n d e n c i e s in a family. E v e n without the results of this sort of research y e t availablt{ to us, t h e r e are practical considerations vehich will be of benefit to t h e b u s y physician in his b e c o m i n g family oriented, labor e x a m p l e , if he unfailingly notes the reactions of o t h e r family m e m b e r s to an illness in one of their lot, he has not only d o n e possible h o m e w o r k for a f u t u r e date, b u t this information m a y h a v e considerable i m p a c t on the m e t h o d of t r e a t m e n t u t i l i z e d ~ f o r example, hospitalization versus h o m e care, or local hospitalization versus distant hospitalization even t h o u g h m o r e a d e q u a t e facilities a r e a v a i l a b l e f u r t h e r a w a y . T h e decision as to w h e t h e r to allow one family m e m l m r to take c h a r g e of the mc-dieations of a n o t h e r can be of c o n s i d e r a b l e i m p o r t a n c e . Let me give you a few examplt,s that h a v e c o m e m y w a y :

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DON D. JACKSON

1. A man was elected to a high public office and shortly thereafter his wife had a malady that was difficult to diagnose. Her physician as well as her acquaintances considered this a tragedy occurring at an otherwise happy moment. If the physician had seen the couple at any timetogether, he would have recognized that she was extremely bitter about his "ot, tside" activities, and it was several months before a diagnosis was made. She was feeding herself small amounts of arsenic. 2. A couple had an only "delicate" sonwho finally was hospitalized for a schizophrenic episode. With drugs and psychotherapy he made a considerable improvement, but his mother became severely alcoholic and the father committed the Son to a state hospital. The mother had a physicia~l, the father had another, and the son's psychiatrist was in contact with neither. Only after the son had been hospitalized for a long time was there a Confrontation made: that is, that his beiaag in the hospital was not because of his "mental illness" but because of the family's convenience. The son has remained in the hospital. 3. A middle-aged man was addicted to a synthetic narcotic which had been given to him originally by his internist for severe gastrointestinal symptoms. He was in many ways a difficult patient and his wife spent long hours nursing him. When his internistwas able to almost force him to cut down on medication, a discrepancy appeared in that the amount of medication ordered continued to be high. It then ",,,,as revealed that the wife had been taking the narcotic along with several other medications and was more severely addicted than the husband. She had been overlooked as a possible patiel{t f6r nearly a year. I am sure that all physicians can recount similar experiences. Just as he would not treat a typhoid patient without inquiring as to the source of the water he drank, a family-oriented physician will not think of illness in one member of the family as a single instance, but wi]I pool it with his knowledge of the family as a whole. ,#

REFERENCE I. Kellner, R.: Family Ill HealthwAn In-

vestigalion in General Practice. New

York, Thoma,~and Sons, 1963.