The modern physician does not treat disease, but rather a living, feeling, thinking, doing individual with a complaint problem expressed in physical and psychic terms.

When a patient comes for medical help, the first objective of the physician is to acquire an understanding of the basic nature of the illness. He seeks first to elucidate the character and mechanisms of the symptoms, and then to detect the various etiologic forces behind them.

... But how is the physician to go about this? Obviously he must inquire into the workings of the patient's mind and the nature of his emotions. To do this well requires skill no less than does a competent physical examination. Some are born with a gift for understanding people as persons but others who are not endowed with this gift may easily acquire this talent.

... A more rounded and more useful picture of the patient is obtained if we try to see him as a whole at different periods of his life rather than in different activities of his life. It may be helpful to have in mind the whole span of a person's school life or his work record; but it is even more helpful to have a picture of the whole person as an infant, a boy, a young married adult and so on. For each of these and for other periods of life we want to have some information about what can be called the emotional climate in which the patient lived. What were the dominant forces in the moulding of his personality? What were the values, the goals, the attitudes of the people who surrounded him? To what stresses were they exposed? How much of these stresses were obviously of their own making? How did they and the patient react to such stresses? To what extent has the patient resisted or thrown away the attitudes which he learned as a child?

... The first clue to topics of emotional significance lies in the material which the patient himself wishes to talk about. Everyone talks about what is important to him. Material which is emotionally charged is under pressure within the patient and seeks outlets. The patient should be allowed to let it out. The relevance of the material produced by the patient spontaneously may not always be immediately apparent but this is usually a reflection of our slowness in understanding. As long as the patient is talking he should rarely be interrupted. ... hesitation, and blocking betray emotional tension; so may their opposite--a quickening of the speed of speech as if from internal pressure. We must watch also for a change in the tone of the voice, irrelevant laughter, dryness of the mouth, restless movements of the hands or body, slight flushing of the face, a turning away of the eyes or the glistening of early tears... .

Within the limits of his own mood, the doctor should show some flexibility in his emotional response to the patient. If the patient is anxious, the doctor should be firmly reassuring; if he is depressed, the doctor should be optimistic but not exuberantly cheerful; if he is angry or suspicious, the doctor should be friendly but not ingratiating or defensive ...

Short cuts in psychiatric history-taking belong to the experienced, who do not often use them. Almost always a number of hours in the aggregate will be required. Too often the physician feels the need to propose a diagnosis following the first examination. Rarely does a patient really demand this. As mentioned previously, it is difficult for the average patient with psychoneurotic or psychosomatic illness to discuss his emotional disturbances even if he suspects they exist until he has first described his clinical symptoms at some length ...

If it is objected that the busy practitioner cannot possibly afford this extra time, it may be pointed out that delaying psychiatric therapy in patients needing it may in the long run take up much more of the physician's time by forcing him to deal with complaints arising from psychiatric disorders. A review was once made of the records of a series of patients whose hospital and outpatient clinic charts each weighed in excess of 5 pounds. All should have had psychiatric evaluations in years gone by. It was too late for them ... .

When questions need to be asked, they should be phrased as generally as possible in order to minimize the effect of suggestion. It is better to say, "How did you feel when you had to sell your house?" than, "Did you feel badly when you sold your house?" or, "You must have felt badly when you had to sell your house." Leading questions invite the patient to offer a routine or cultural attitude which may not be truly his. The patient might have been partly or wholly pleased at having to sell his house but be unable to admit it after a question suggesting disappointment. If, however, it is apparent that the patient is unaware or unexpressive of all his feelings about an event, a suggestive interpretation may be made cautiously in an effort to draw him out further. For example, one might say, "Perhaps you weren't altogether sorry to see your house go," or, "I imagine your father's remark might have made you a bit angry as well as embarrassed."

Little information is obtained by such questions as: "How do you get along with your father?"--"Do you worry much?"--"Do you like your older brother?" The patient will almost certainly answer with sterile replies, replies designed to satisfy cultural attitudes ... When the opportunity provides, the patient should be drawn out into anecdotal relation of events in which he was associated with relevant persons. Much more can be learned from a study of such anecdotes than from standardized statements such as, "Mother favored my younger sister" or "Dad was always fair to us." When a patient makes such statements he should be asked, "Can you give me an example of this?"--IAN STEVENSON, M.D. and ROBERT A. MATTHEWS, M.D.

Commentary

Some things never change, and human nature is one of them. Although our understanding of science and technology has advanced greatly in the past 50 years, suffering and somatization remain remarkably constant. Nothing, in my view, can replace the basic techniques of open-ended questioning and empathic listening that are outlined in the excerpts above. As we read these selections, many of the authors' suggestions--behaving in a supportive manner to our patients, encouraging them to express themselves, avoiding leading questions--seem almost too obvious. We have, after all, become increasingly sophisticated about the mind-body connection, and we have come a long way toward incorporating the psychologic aspects of illness into our teaching programs.

However, with our increasing refinement has come a decrease in opportunity to use this knowledge. The authors address the importance of taking time with patients, asserting that the "short cuts in history-taking belong to the experienced, who do not often use them." In our day, the short cut has become the standard in dealing with emotional problems in medical practice. Such a short cut can come in the form of criteria from the Diagnostic and Statistical Manual of Mental Disorders--for example, those for depression--for which we can prescribe an antidepressant. Or it might come in the form of an abbreviated psychotherapeutic method, such as the BATHE technique, which is designed to fit smoothly into a 15-minute appointment. Although pharmacotherapy and brief interventions have an important place in the treatment of patients, they are likely to miss a large percentage of those whose troubles influence their health without constituting a psychiatric diagnosis. The benefits of a long-term relationship with a physician who knows the "whole patient" are not fully known and in practical terms are probably greatly underestimated.

Something in the authors' language shows how different, after all, our approach has become over the past 50 years. They write: "We must watch also for a change in the tone of voice, dryness of the mouth, restless movements of the hands or body, slight flushing of the face, a turning away of the eyes, or the glistening of early tears." If the language we use is any indication, we no longer live in an era that allows us to give all our patients such careful attention and empathy.--CAROLINE WELLBERY, M.D.