Andrew Rix is a behavioural scientist with research interests in health and social care. He was diagnosed with Parkinsons in 2010.
Andrew Rix took part in our first webinar of 2020, which explored a clinical case of a person known as ‘Paula’.
The recent Rethinking Medicine webinar used the Balint method to explore alternatives to the bio-clinical approach. The technique involves a discussion among clinicians to explain connections between psychological factors and physical symptoms.
‘Paula’ had any number of symptoms, some verifiable by clinical testing, but many not. Her life seemed sad and lonely. She changed her address almost annually and could not hold down a job. Improvements in one part of her condition were counterbalanced by deteriorations in others. Frequent appointments and new symptoms led to constant referrals where the cycle of attempted diagnosis was repeated at an increased expense.
The doctors ‘treating’ Paula felt frustrated, apologetic and embarrassed at their failure to make sense of the many strands of clinical information her appointments, consultations and diagnostic tests generated. Webinar panelists Alf Collins, Martin Marshall and Luisa Pettigrew sympathised with the doctors who had tried and failed to help Paula as a patient within the current system.
Doing as we’re taught
The panelists suggested that, while Paula’s doctors saw the medical model as the solution to her problems, perhaps it was (at least partially) the cause. Paula’s uncertain health status was not being improved by the deductive process that evidence-based medicine relies upon.
It encourages repetitive behaviour, not just in physicians, but in patients too. Jocelyn Cornwell reminded us that we have all been schooled to behave in ways that support the medical model. Paula was doing what we have all been taught to do: responding to the clinical encounter by presenting clinical symptoms. Jocelyn proposed that Paula needed someone to stand alongside her, not more assessment. Would this be enough to provoke a ‘different’ result?
Paula needed someone to stand alongside her, not more assessment.
Writing your own script
The discourse between doctor and patient is as scripted as any traditional drama. Roles are assigned, stereotypes used as shortcuts to understanding and the plot kept on track by genre-based conventions. Yet Paula seems to have been given the wrong script – she keeps asking the wrong people for the wrong things. The rest of the cast try to give her cues, but they cannot improvise too much because they have their own scripts to think about. In a film, this would lead to endless retakes to ensure the words spoken match those in the script.
Alf’s plea to “listen to patient’s stories” about their lives and not just their illnesses is akin to letting the actors write the script as they go along. This calls for a very different method of production and skill-set. It also involves greater risk and much higher levels of trust between director and actor.
Paula seems to have been given the wrong script – she keeps asking the wrong people for the wrong things.
The cost of seeing the person
The Balint method was successful in opening up new approaches to understanding Paula’s health issues. However, seeing Paula as a person instead of an unfathomable bundle of symptoms is going to involve longer consultations, different inputs and better coordination of information than the system currently allows.
We need to move beyond GPs “reading between the lines” to allow Paula to tell her own story. Yet this discourse may threaten doctors’ authority, and requires patients to take on responsibility in unskilled areas. We need to evolve from talking about Paula to listening to Paula talk about herself, but it’s a big step. Ask Mike Leigh.