Good doctor, bad doctor—a psychodynamic approach
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7366.722 (Published 28 September 2002) Cite this as: BMJ 2002;325:722
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Spot on Dr Holmes. You articulate my thoughts on the matter
precisely. Nobody is perfect. The single most important attribute of a
good doctor is insight. That is to say the ability for detached
observation of one's thoughts and emotions without judgement but
recognition of the propriety of the expression of that response in a given
context. We are all as thespians in our professional role. It is important
to recognise this and to have the capacity to drop the acting outside the
job and live a normal life.
Insight also gives one the capacity to recognise the limits of one's
medical ability and to refer appropriately.
Yours sincerely
Andrew Montgomery
Competing interests: No competing interests
Jeremy Holmes raises the issue of the "good-enough" doctor.1 In October 2000, I was suspended by my NHS Trust for 6 months and underwent a period of supervised practice for a year following a recommendation from the Royal College of Psychiatrists.
I am a founding member of the Critical Psychiatry Network (www.criticalpsychiatry.co.uk). For several years I have maintained the Critical Psychiatry website (www.anti-psychiatry.co.uk), initially called the Anti-psychiatry website.
I regard myself as a good psychiatrist. It was a shock to me to be accused of incompetence. However much the suspension and recommendation for retraining and supervision was motivated to alter my opinions about psychiatry, my critical views remain the same. Essentially I recognise that psychiatry may be part of the problem rather than necessarily the solution to mental health problems. As far as the Critical Psychiatry Network is concerned, psychiatric practice does not need to be justified by postulating brain pathology as the basis for mental illness.
As Holmes advocates, I have become a patient by undergoing psychotherapy, which I wanted to do previously but never, or so I thought, could afford. My current therapy has so far been paid for by my NHS Trust, maybe partly because of its acknowledgement of the psychological impact of the suspension.
I did take on too much work before suspension, undoubtedly motivated, as Holmes says, by my own "fragile sense of competence and health", and also the extra payment on offer. Nonetheless I still regard what I was providing as "good-enough".
Even my most vociferous critics have not challenged my integrity and good faith. In my naivety, I regarded these characteristics as sufficient protection against accusations of incompetence.
Holmes suggests that the question of why bad or harmful practice continues remains unanswered. Taking a stance for good practice in current health work may be a vulnerable position. The reaction to whistleblowers is an example.2
Holmes' message to me may be that not taking a biomedical perspective on psychiatry does not necessarily make me a better doctor. Nonetheless I do think the explanatory model of mental illness that is used in mental health work is important. There is an orthodoxy about current biomedical psychiatric practice that feels threatened by criticism.3 The limits of psychiatry and medical practice in general do need to be acknowledged.4 How good a doctor is has to be understood in the dynamic of the power relationship between doctor and patient.
1. Holmes J. Good doctor, bad doctor - a psychodynamic appraoch. BMJ 2002; 325: 722
2. Hunt G (ed) Whistleblowing in the health service. London : Edward Arnold, 1995
3. Double DB. Integrating critical psychiatry into psychiatric training. In: Newnes C, Holmes G and Dunn C (eds). This is madness too. Ross-on-Wye: PCCS Books, 2001
4. Double DB. The limits of psychiatry. BMJ 2002; 324: 900-904 [Full text]
Competing interests: No competing interests
Psychodynamic approaches
Dr. Jeremy Holmes article on a psychodynamic perspective of
consultations is very useful. As someone who has had psychodynamic
psychotherapy and sees my work with mental health service users from a
psychodynamic perspective, this article was superb in putting across what
patients want.
No matter what a doctor's speciality is, whether a GP or registrar in
psychiatry, patients want to be heard and empathised with. The National
Service Framework in Mental Health placed great emphasis on primary care
and management. I spend a great deal of time on a NSF primary care working
group with GPs and other mental health professionals including a Senior
Tutor in Psychiatry. And the ten minute issue comes up so often. However I
know from personal experience, psychodynamic thought and perspective gives
a better outcome in many cases (Bateman, A.W. &Fonaghy, P.). There is
a lack of this due to a lack of resources for training, which is a
concern.
Fenella Lemonsky
Ref: Bateman, A.W. & Fonaghy. Amer Jour Psy, Jan 2001.
Competing interests: No competing interests