AFP 50 Years Ago

Am Fam Physician. 2000 Jul 15;62(2):288-291.

This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.

This feature, titled “Emotional Problems of the Chronically Ill,” is reproduced from the December 1950 issue of GP. It was written by George Saslow, M.D., of Washington University School of Medicine, St. Louis, Mo. The commentary is provided by G. Gayle Stephens, M.D., emeritus professor of family medicine, University of Alabama School of Medicine, Birmingham, Ala.

There are certain emotional problems common to the chronically ill … All such patients require lifelong attention as they take treatment with drugs, or have to limit their activities, or give up their work, or meet exacerbations, complications, relapses, or the need for surgical treatment.…

Evidently many a patient with chronic intermittently disabling disease has difficulty in sustaining his cooperation with his medical advisers.… threats of certain disability or death (“striking the fear of God into him”) are less effective than we would like to believe.

Experience with the psychiatrically ill has taught us some effective ways of increasing a person's capacity to adjust to stressful life situations (of which chronic illness is one). We shall describe in some detail how this experience may be applied to … the patient with tuberculosis…

These principles are (1) recognition that a patient is probably in emotional distress, (2) encouragement to express such distress in words, and (3) brief, calm presentation to the patient of the alternatives before him, once his intense emotion has been discharged and he is able to listen.

The tuberculous patient is most likely to benefit from the application of these principles during three epochs: (1) at the time when he is told what is wrong with him, (2) while he is in the sanitorium, and (3) when he is ready to resume ordinary life.

… the patient who is seriously distressed emotionally often goes into a “blackout” and absorbs nothing after he hears the words “you have tuberculosis.”

… If a woman needs to cry for five minutes, that's what she should be allowed to do….

A doctor can hardly act in the way described unless he gives 30 minutes or more to his patients in privacy…

The procedure described above has the important objective of establishing a strong patient-doctor relationship which as a rule generalizes to other medical personnel upon whom the patient must depend.

Commentary

This gentle article written by a wise and humane clinician in 1950 reminds us of how the world of medical practice has changed and yet how it remains the same. It is prescient in the choice of chronic illness as a topic for clinical instruction, but who, writing today, would select tuberculosis over cancer, chronic obstructive pulmonary disease, atherosclerosis, arthritis, diabetes, acquired immunodeficiency syndrome, chronic pain syndromes or substance abuse as the model disease? For that matter, what journal editor today would accept an unreferenced article on such a broad topic based mainly on the author's experience? Once a staple of medical writing, the clinical essay is now passé, part of a world we have lost.

In fact, however, tuberculosis provided an important chapter in our ability to understand illness beyond the simplistic notion of cause and effect derived from the germ theory of disease. George Engel1 was one of a dedicated group of investigators, mainly psychiatrists and internists, who wrote about psychosomatic diseases in the middle of the past century, and he used tuberculosis as an example of a “Unified Concept of Health and Disease,” in which host factors were considered as important as germs in producing illness. This work preceded by 15 years his “Biopsychosocial Model of Disease,” which became a favorite reference for academic family physicians.

Saslow's article in AFP clearly draws on this early foundation in psychosomatics, which may be understood as a combination of psychodynamic psychology and physiology of the autonomic nervous system and endocrinology. His deceptively simple, common-sense advice rests on a belief in the therapeutic efficacy of clinical conversations within the context of intimate, trustworthy and durable patient-physician relationships, which can allay anxiety, dilute resistance to treatment, facilitate optimism and promote healing. This method of practice was later made more accessible to general practitioners by Michael Balint,2 who studied patient-doctor interactions and proposed this metaphor, “the doctor as a drug.”

Nowadays, when medical practice has become more fragmented, plied by an army of experts, constrained by the demands of the market and in some ways more dangerous to patients,3 the low-tech, personal methods of Saslow, Engel, and Balint have undergone attrition. How long has it been since you spent 30 minutes in conversation with a patient or waited 5 minutes to allow one to cry? Are things really better for patients with a chronic disease—more likely, multiple chronic diseases? Such patients increasingly are voting with their feet to seek outside the mainstream what is lacking in standard medicine.

As family physicians, we could do worse than hear again Saslow's voice from 50 years ago when next we encounter the “Emotional Problems of the Chronically Ill.”—g. gayle stephens, m.d.

REFERENCES

1. Engel GL. Psychological development in health and disease. Philadelphia: Saunders, 1962.

2. Balint M. The doctor, his patient and the illness. Rev. ed. New York: International Universities Press, 1972.

3. Kohn LT, Corrigan J, Donaldson MS, eds. To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000. Retrieved from the World Wide Web May 2000 (http://books.nap.edu/catalog/9728.html)


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