THE OBJECTIVE TANGENT

1340 out.

Patient and Doctor THE

OBJECTIVE TANGENT MICHAEL ROSE

Department of Hœmatology, St. James’ Hospital, London SW12 8HW, and Department of Hœmatology, St. George’s Hospital Medical School, London SW17 0QT FIRST MOVEMENT

been struck by the frequency with which it is that a patient’s troubles are all fixed possible up only to discover that the complaint for which he first consulted the doctor remains unchanged or has become worse. A typical case-history reads thus: "55-year-old immigrant from East Africa has had severe frontal headaches which develop during the course of the day, almost every day for years. She has a blood-pressure of 150/110 mm Hg and iron-deficiency anaemia." Over a period of many months her blood-pressure falls and she is discharged from medical outpatients; her haemoglobin returns to normal and I suggest that we could call it a day. "What about the headache doctor?" I look at the fundi and can’t see the left one. I think that there’s a beam in her eye and refer to the ophthalmologist, pretty confident that neither her anxmia nor non-anxmia account for the headache. And so it goes. The objective tangent is the trail we follow that has nothing to do with the patient’s subjective trouble. It is neither a crime nor is it stupid to follow this trail. It is not easy, and it is often impossible, to know that it is a false trail until one is told, when flushed with victory, that the finishing post is still a long way off, perhaps further off than it was when you started. Often when we’ve done our best, it’s not easy to accept that it has all added up to nothing to the fellow or lady on the other side of the consulting table. Then seems the time to hand over the patient like a baton in a relay race. Meanwhile, no doubt, "the whole patient" (more than the molecular aggregate) is receiving succour for the spirit from the I

HAVE

to assume

general practitioner.

Down the fourth tunnel again. No cheese. Comes out. the rat will stop going down the fourth tunnel and

Eventually

look elsewhere. "Now the difference between rats and human beings is simple: the human beings will go down that fourth tunnel for-

ever ! Forever! Human beings come to believe ininterestedtun-

nel. Rats don’t believe in anything; they’re interested in cheese. But the human being develops a belief in the fourth tunnel, and he comes to make it right to go down the fourth tunnel whether there’s cheese in it or not. The human being would rather be right than get his cheese."’t

This is not to deprecate either objectivity or the devices which we have inherited for the calibration of our objective data, only to point out that it is really a tributary frequently mistaken for the mainstream. ARMIES OF THE NIGHT

The late Dr Schumacher,. erstwhile high priest of intermediate technology, has left us a treasure. He classifies the sciences as "descriptive" ("what do I actually encounter?") and "instructional" ("what must I do in order to abtain a certain result?"). He warns: "It is no exaggeration today to talk about a crisis of (instructional) science. If it continues to be a juggernaut outside humanistic control there will be a reaction and revulsion against it which would not exclude the possibility of violence."2 Perhaps the origins of the current state of professional depression are not to be found in an unhappy relationship with the D.H.S.S., or in the scale of uninspiring salaries under which we labour, but in the knowledge that we have been press-ganged into a journey we never really intended to take. The eating of this pudding is in the proof. There can never be proof in descriptive science. "There can be classifications, observed regularities, speculations, theorems of different grades of plausibility ... Endless trouble ... arises when the methodological requirements of the instructive sciences are taken as scientific methodology per se. Applied to the descriptive sciences, they lead to a methodology of error. The restrictions of pragmatism, heuristic principles, or Occam’s razor are not compatible with truthful descrip-

tion. "3 CHORUS LINE

SAY

"CHEESE"

Well, what do you do with a polysymptomatic patient in whom the only positive finding is an enlarged liver? You know that whatever you find can have no conceivable bearing on any or all of the symptoms. I’ve no idea. The objective tangent is the familiar path, the path which we have been trained to follow, the one we’d claim to be skilled at following and to know our way around. How often do you fall for it? Probably for ever and always. "If we put a rat in a maze with four tunnels and always put cheese in the fourth tunnel, after a while that rat will learn always to go to the fourth tunnel to get cheese. A human being will learn to do that too. You want cheese? Zip zip zip down the fourth tunnel, there’s the cheese. Next day you want cheese? Zip zip zip down the fourth tunnel, and there’s the cheese. "Now, after a while the Great God in the white suit moves the cheese to another tunnel. Zip zip zip goes the rat to the fourth tunnel. No cheese in the fourth tunnel. The rat comes out. Goes down the fourth tunnel again. No cheese. Rat comes out. Goes down the fourth tunnel again. No cheese. Comes

When one abides strictly by reputable scientific principles it is perplexing to discover that they become progressively more suspect, progressively less useful, more predictably disappointing. It is alarming to discover that the shortcomings cannot be resolved by reading more learned periodicals and each new edition or modern textbook, or by getting a bigger department with more staff and money. That sort of learning is an evasion of the opportunity to observe and test the matters which concern us ourselves. It may be argued that the students selected for the privilege of following this false trail are the ones who learn the most easily and have the least resistance to the nonsence which they are taught. What they learn equips them for "starting on a Polar expedition with summer clothing and maps of the Italian Lakes.4 Lucky boys and girls on A Chorus Line, doomed by their early success, need never look elsewhere. (A Chorus Line is a musical which follows the auditions and selection of boys and girls for the chorus line. Those who fail have the chance to come up with something better ; those who succeed are stuck. The sentiment is

1341 reminiscent of Robert Browning’s Rabbi ben Ezra.) "All knowledge is obtained in accordance with the cognitive powers of the knower.115 Being able to learn quickly is not

always a great asset. A FOR ANEMIA

We must distinguish between knowledge and belief. I know that if I give tablets "A" the anaemia will go away; I believe that this will cure the headache. It may be a fatuous belief. I deal with what I am competent to deal with, and often enough it is just an irrelevant exercise in clearing up. The wrong question prohibits asking the right question. What business is it of mine to discover what the trouble is? Meanwhile she has her piles fixed, her gallbladder removed: "Mrs R was admitted to a large Sydney hospital on Jan. 19, She had been previously admitted to the same hospi1975 On the occasion of the 1974 admission tal in August, 1974 she had complained of symptoms of peptic ulceration and had undergone tests and treatment in respect of this ulcer. On Aug. 28, 1974, the patient states ’I am now 84,1 have had an ulcer for thirty years. The symptoms are not increasing. I can live with the ulcer but I cannot live with any more tests.’ She was discharged a week later. Between Jan. 19, 1975, and June 15, when the Lord, or fate, relieved her suffering, she had undergone five months of investigation and treatment for her gastric ulcer and various conditions unearthed, or produced, by the miracles of modern medicine. One month before her death, a brief truce was called and she was transferred to a convalescence unit. Regrettably, she became the victim of a cerebrovascular accident, followed by epileptiform seizures. She was readmitted and underwent investigations to elucidate the cause of her epilepsy. Mercifully, she died before diagnosis was established. During her hospitalisation she underwent the following ...

...

investigatory procedures: 39 biochemical profiles 45 haematological examinations 21 microbiological tests 2 bone-marrow aspirations 11 chest X-rays

.

5 barium meals 16 electrocardiograms 2 electroencephalograms 1 brain scan 4 lung scans 1 gastroscopy ,

7 blood-transfusions She had consultations on two occasions with gynaecologists, two with surgeons, and one with an ophthalmologist. During the five months, she had a total sum of 37 different medica-

ments."6 MEASURING THE WASTELAND

This is expensive flotsam, but it hasn’t all just washed ashore by accident. It is the central process: "It is impossible to escape the impression that people commonly use false standards of measurement-that they seek power, success and wealth for themselves and admire them in others ..." If people could really direct the activities over which they have power, some purpose and ideology might emerge. But the machinery over which they preside has its intrinsic imperatives for which no-one is either able to or wishes to accept responsibility. "In reality the machine replaces manual labour; according to criticism it replaces thought."8 So long as the machine grinds on, no-one’s feet touch the ground for long enough to attend to that headache. Headache? Everybody has a headache-what is so special about hers? She came to a blood doctor who fixed her blood, and believe

it wasn’t easy to concentrate with her rabbiting on about her headache all the damned time. The step onto an objective tangent is taken when an abnormality is detected, explored, explained, attended to, and corrected without the patient feeling any better. How can we know what a patient feels? Are we really to rely on such nebulous directives instead of hard reproducible data-the chemistry, physics, and statistics of it all? Schumacher’s answer is yes: "A person confining his attention solely to what can be counted, measured and weighed, lives in a very poor world, so poor that he will experience it as a meaningless wasteland unfit for human habitation."9 No amount of measurement will make the old young, the sad happy, the stupid bright. There are some things we are landed with and no amount of medicine or measurement will do more than pass the time of another boring day. It is precisely our bright command of the accurate means to measure which commits us to measure the measurable, however irrelevant to the task in hand. Perhaps that is because our professional society is structured so that we are measured insofar as we measure. Well, that’s a bit utopian too, but let us just suppose that the schools and training programmes work according to plan, which thank goodness they don’t. Doctors would be able to get their work more and more right in as much as they could measure more often and more precisely. How right can it be? It cannot be a second act of creation.

me

PHOTOGRAPH THE PHOTOGRAPHER

unless it is important. Who knows what is important? Well, if a doctor doesn’t know what is important, what is so important about doctors? So, if we’re important we must know what is important. How? By finding out. We come out of medical school weighed down by a lot of the stuff which must have been important to the people who taught us. Why else waste so much time? In those gracious days in which I studied there were no penalities for absence. Today a student misses a session or two and memoranda ricochet among the academic collonades. So he won’t know about tularaemia. Too bad. Once he has grasped the discipline (who wears what kind of coat, which tubes to put arterial blood into, how the body works and fouls up, what time to get up in the morning) then the most important thing to cultivate is himself. What an arrogant and outrageous statement. Well, how else can you work out what other people are talking about without considering what you mean, say, and do and without acknowledging the unreliability of each as a statement of the others? The obvious answers derived from our training are too often wrong to be reliable and with more of the same it makes it more difficult to find an alternative road which looks more hopeful. Does a doctor function best intending to assist his patient as a molecular aggregate or as an individual whose self-awareness approximates to his own? These are not exclusive options, but which takes the higher place? If by analysis and manipulation of the molecular aggregate he serves the interests of his self-aware patient, then well and good; but if he is just keeping the shop tidy what is the point of that? We have no access to the self-awareness of others except through the recognition and cultivation of our own. Schumacher proposes Do

nothing

1342 four fields of knowledge in respect of the relationships between people: 1. What do I feel like2. What do you feel like? 3. What do I look like? 4. What do you look like ?9

that we are what we appear to everyexcept ourselves, we must accept that our only entry into what someone else feels is how we feel ourselves. We know very well when what we’re doing is important and who it is important to, and furthermore we know how it would feel to be assessed on such absurd criteria by others. A patient’s calcium balance may be important, but if the most interesting thing about the patient seems to be his calcium balance, it is likely that something important is being missed, if only how unusually dull the patient is.

Acknowledging

one

THE RECOGNITION OF NECESSITY

A final distinction needs to be made between an objective parallel in which results code for an explanation for the patient’s trouble and the objective tangent which is an expensive holiday from reality. The deal stands: "I am unwell, please attend to me"; not "I am unwell, why don’t you mess around with me a little?" CorrespondINTERPERSONAL PSYCHOTHERAPIES IN

MEDICINE A. H. CRISP

Department of Psychiatry, St. George’s Hospital Medical School, Tooting, London SW17 0QT One person can sometimes influence another in a face-to-face encounter, and in psychotherapy the aim is to maximise this effect, when appropriate and possible, for relief of distress, modification of disease processes, and/or growth of per-

Summary

sonality. INTRODUCTION

PSYCHOTHERAPY is taken here to mean that aspect of treatment, sometimes the sole and intended aspect and

sometimes

which is concerned with modifying the patient’s experience of himself and his behaviour through interpersonal transactions between him and the not so,

therapist. Doctors have long recognised that patients whose lives are threatened by illness may need more emotional support than medical competence alone can provide. Many doctors attempt to give this support by such conscious means as reassurance and attention to the patient’s social problems, and sometimes their concern is valuable. Physicians in earlier centuries were aware of the role of psychological factors in the precipitation and course of many diseases, but their observations usually left them therapeutically impotent. Today, however, we are more fortunate, for Pavlov and Freud, who looked at behaviour from two very different viewpoints, have left us very thorough analyses which have enabled us to explore the role of experiential factors in disease and their experiential modification. THE ORIGINS OF PSYCHOTHERAPY

In animal

experiments

Pavlov showed that

behaviour,

ingly, the doctor’s part of the bargain is:

"I’ll see if I can find out what’s the matter and try to do something about it"; not "I’ll try to find out whether there’s anything the matter in my sphere of interest and fix it in any case, then I’ll hand you on to the next specialist and you can jump through his hoop." Each, attending to the bits and pieces of his trade, must convince himself that what he is doing is important to the self of his patient, which he can only know indirectly, through knowing himself. That is a new morality which specialisation thrusts before us: the restraints of necessity and relevance.

to

I am most grateful to Prof. the Australian Newsletter.

John Owen for drawing my attention

REFERENCES 1. Rhinehart, L. The Book of est; p. 21. New York, 1976. 2. Schumacher, E. F. A Guide to the Perplexed; p.121. London, 1977. 3. ibid. p. 122. 4. Freud, S. Civilisation and its Discontents (translated by James Strachey); p. 81. New York, 1966. 5. Schumacher, E. F. A Guide to the Perplexed; p. 123. 6. Royal College of Pathologists of Australia. Newsletter. August, 1977. 7. Freud, S. Civilisation and its Discontents; p. 11. New York, 1966. 8. Marx, K., Engels, J. The Holy Family, or Critique of Critical Criticism (translated by Richard Dixon and Clements Dutt); p. 17. Moscow, 1975. 9. Schumacher, E. F. A Guide to the Perplexed; p. 45. 10. ibid p. 74.

visceral responses, can become attached to irrelevant cues, including social ones, by classical conditioning. Others have demonstrated that the basal levels and intensity of such behaviour, again including visceral responses, can themselves be modified by operant conditioning. It seems likely that such effects can operate in normal human development, thereby linking the individual’s visceral activity to his environment and his developing character structure. In the past two decades "behavioural" types of psychotherapy have arisen which have aimed at the modification of disordered muscular and visceral activities and their experiential components and consequences. This kind of behaviour therapy has important affinities with the interpersonal psychotherapies described below. Freud demonstrated the importance of early life in the formation of the human constitution, especially character structure. Working with adult patients with mental illness or problems of life adjustment, he built up an elaborate treatment method (psychoanalysis) and an equally elaborate theory of human development. He claimed that in adult life we compulsively re-present attitudes and repeat experiences first established in infantile and childhood relationships with our parents. This notion is similar in some respects to the behaviouristic view of human development. Freud, however, went on to several further important propositions. First, he found sexual needs to be the central determining factor in human development from birth. Secondly, he postulated a repertoire of unconscious psychological mechanisms, including repression, conversion, and projection, which enable human beings to cope with emerging conflict. Such mechanisms are thought to be homoeostatic, protecting the individual from the conscious experience of the worst of the conflict; but in doing so they distort his perception of the world and of human relationships and often also produce unattached or misplaced anxiety. Thirdly, Freud found the basic conflict-between the individual’s instinctual and social

including