Abstract
The first year of my GP training expedition has come to an end. I was privileged to have a competent and enthusiastic registrar. It's rewarding to see a trainee flourish into a more autonomous practitioner. I hope that I have transferred some useful skills that will be used for the greater good. Along with the end of my current trainer—trainee relationship comes the excitement of a new trainee, a new seedling to nourish with experience and wisdom. I myself am a trainee in the context of post-graduate medical education and hope to continue to learn and reflect on good teaching practice.
I was quite taken aback recently when a patient was giving me positive feedback, ‘doctor; even when you don't give me medicine I still feel better’. This made me reflect on the power we have as doctors to heal when the only treatment we provide is ourselves.
Balint (1964) described, ‘By far the most frequently used drug in general practice was the doctor himself’ and ‘no pharmacology of this important drug exists yet’. He also stated that ‘experience and common sense will help the doctor to acquire the necessary skill in prescribing himself’. This perhaps abstract, yet very relevant, concept does not get the recognition it deserves in GP training. How many tutorials have discussed the registrar as a form of treatment? Should we be asking ‘so how are you getting on with prescribing yourself? Have you learnt what dose particular patients need?’ Some patients just need their GP once a fortnight or so. Perhaps, this gives them the sense of security and stability they require. I certainly think it is rare to have a patient with such insight as to disclose that comment. Very flattering indeed, but I do not think my skills are unique. I believe that this is a testament to the long-term continuity we offer as health care professionals. Could a doctor in casualty have the same effect? Perhaps, they could.
The patient who gave me this feedback had not been given any medicine so is my consultation a type of placebo? It seems that this patient has impressive insight into the psychological aspects of the consultation. This makes me reflect on my performance in the consultation. Are we as doctors invariably ‘acting’ in the consultation? How much of what we say is really sincere? Are GPs professional actors (with or without insight)? Or are we simply acting professionally? The patient who gave me that feedback knows me only as a GP in the professional context. Certainly, the consultation is a deep ocean of psychology and relationships. Whatever I am doing with that particular patient, it is working well or at least seems to be.
The power of placebo cannot be underestimated. I sometimes wonder about the benefit of using placebo for certain presentations, though ethical constraints inhibit the use of this possibly effective tool. So are we embracing it enough?
The concept of the consultation as placebo reinforces the benefit of communication skills, notably getting the patient's agenda; if a patient is only looking for reassurance and a sense of support, it helps to know this and may reduce the risk of unnecessary investigation or referral.
The concept of the consultation as a therapeutic medium in itself also reinforces the need for peer support and more notably the ‘Balint group’. This is the training ground for the doctor to share ideas, confirm thoughts and skill up as a therapeutic tool. If we as doctors are treatment in ourselves, we must refine and improve our delivery and dosage. Consider it ‘quality control’ that all medicines have to undergo.
I hope this discussion helps to empower any aspiring trainees to understand what powerful therapeutic tools they can become and to embrace with insight the changes they can make to society by knowing how and when to deliver themselves to their patients. Happy healing.