Abstract
Biographies in theory and in practice
The Journal of Medical Biography interests doctors, health professionals and historians since every branch of medical practice has people, the stories of whose lives are of continuing interest.
But biography has a special place in two branches of medicine, being integral to practice in both psychiatry and general practice. In both fields, understanding of the story of the patient's life is often necessary for diagnosis, management and prognosis. Of course, in both fields there are conditions that can be diagnosed and managed competently as one-off incidents without such a personal approach.
Within psychiatry, the psychotherapeutic and psychoanalytical schools 1 emphasize biography. In general practice, those practising continuity of care 2 develop a biographical approach. Both groups of doctors piece together the story of a patient's life. However, psychiatry and general practice do this differently. In psychiatry consultations with new patients usually last about an hour and include a structured history; general practitioners learn the patient's life-story over a long series of shorter consultations, often over many years.
The Journal of Medical Biography is strong in illuminating how individuals have influenced and sometimes formed branches of medical practice. Similarly, family doctors learn how people have formed and influenced families, sometimes over generations. Many common conditions in general practice have familial patterns, for example asthma, depression, diabetes, epilepsy, ischaemic heart disease, obesity and some forms of rheumatism. For these conditions, knowing the family history influences probabilities in diagnosis and outcome. Many a man lives in fear following a father's early death, just as many women acutely fear familial breast cancer. Some childhood events, like sexual abuse, may dominate a personality and alter consultation patterns over a lifetime. Such biographical landmarks illuminate what can superficially seem ‘minor’ or apparently ‘trivial’ consultations.
Professional listening is a considerable skill and is easiest in family practice for three reasons: consultation patterns, family care and home visiting. Consultation patterns are little known but crucial. The average NHS patient now attends a general practice 5.3 times a year: 2.7 times a year to see a doctor. 3 Assuming a doctor will on average be away on holiday, on courses or at meetings, personal lists 2 still allow a doctor to see each patient some 60% of the time (1.62 consultations a year). Given the average consultation time of 13 minutes this equates to 21.1 minutes a year. Integrating the median duration of registration of patients with their doctor of 7.9 years, then the average patient attending has spent 166.7 minutes (two and three quarter hours) face-to-face with their doctor before entering the consulting room. This is plenty of time to get to know the patient as a person. A median of 7.9 years has an upper interquartile range which means that in some practices a quarter of the total number of persons has been registered with the same general practice for 21.5 years. 4 Many attend on more than one hundred occasions. Biographical advantages in family practice include seeing spouses, partners, children and other family members. Many a strong patient–doctor relationship started when an adult consulted repeatedly for a child. Finally, home visits can reveal hobbies, interests, prizes, lifestyle factors and people like lodgers – all may be illuminating.
Canadians 5 showed how many health problems flow from human behaviour. Hence family medicine draws from behavioural sciences including psychology, sociology and anthropology. General practice can also learn from historians and biographers' ways of weighing evidence and unravelling motivations.
A career in general practice unfolds roughly in decades. In the first decade the main emphasis is on physical/mechanical problems and solutions. Surprises are common. After 10 years behavioural aspects loom larger and many medical problems are seen to have behavioural antecedents. After 20 years in the same practice, many of those first met as girls become mothers, parents become grandparents and grandparents become great-grandparents. Information now reaches the doctor from many sources – a grandmother saying ‘Doctor, she's not coping with that baby’ – is almost always right. The biography of a family merges with family practice. Chronic, long-term incurable problems loom larger.
Finally, a minority of family doctors have the privilege of working for 30 or more years with the same families. The doctor grows older with the patients and, after what can be 200 consultations with various family members, mutual trust 6 is often very strong. The doctor is now rarely surprised by family happenings. These doctors study families, like medical anthropologists, and sometimes become an ‘honorary member of the family’, being given the front-door key in serious illness.
‘Narrative medicine’ 7 studies words, language, metaphors and meaning in medicine, and overlaps with the biographical approach that underpins personal medicine. Personal care is the centre point of general practice, understanding confidences in context and tailoring evidence-based medicine to the wishes and needs of each individual. 8
General practice and psychotherapy can contribute to the understanding and appreciation of biographies, not just of doctors, but of patients too.