A review of some recent work
by F. E. EMERY, M.A.
It is trite to state that medical problems are permeated with psychological problems.
It is, on the other hand, not so trite to specify some of the actual forms of permea- tion. Because such specification is rarely done, and even less frequently done well, there is some value in considering the work of Barker, Gonick and Wright.* Bringing together the results of research already con- ducted in this field they attempt to draw a More complete picture and suggestions for remedial measures.
To confine ourselves to their findings and suggestions regarding "acute illness' we find them posing three questions—
What are the peculiarly psychological problems of acute illness?
How do these arise?
By what means can they be solved?
Thus, within the framework of the medical problems of diagnosis they point to the following psychological problems:
1. Reluctance of persons to seek early medical advice and diagnosis.
2. Emotionality of persons during diag- nosis .(with occasional effects on such diagnostic methods as basal metabolism test).
3. Unreliability of patient's statements about their own symptoms.
Do these problems arise simply from Ignorance of when medical advice should be sought, from traits of nervousness in Some persons, or from lack of training or natural inability in self observation? While
"Adjustment to Physical Handicap and Illness:
)i Survey of the Social Psychology of Physique and sability", by Roger G. Barker, Beatrice A. Wright and Mollie R. Gonick, Social Science Research Council Bulletin, N.Y., 55, 1946.
not discounting such factors Barker et al point to certain aspects of the situation as it exists for the patient, which lead to these forms of behaviour.
The diagnostic situation may appear to the doctor as a' routine technical job. To the patient, however, the situation is much more personal, much more significant.
Consider a person who regards himself as healthy but is concerned about certain disturbing symptoms. He will want to seek medical attention because he believes that it will lead to a remission of symptoms and a return to a state of good health. On the other hand he will want to avoid medical attention because he feels that it is itself painful, expensive, or time consuming, or because he fears that it will confirm a state of serious illness. Thus, such a person is inevitably in a state of conflict, although the strength of the conflict will vary with differ- ences in attitude towards these alternatives.
It is this state of conflict that enables us to understand why many are so reluctant to seek medical advice and why so many tend to exhibit emotional behaviour to the doctor;
why it so frequently happens that some persons are continually deciding to visit the doctor (or dentist!) "next week" only to put it off again when the time draws near.
So long as the situation retains unattractive features a person will tend to keep away from it — a tendency which will increase rather than decrease the closer an individual comes to it. (This conforms to the well established psychological law that the forces away from an unattractive situation increase more rapidly than the forces toward an attractive situation as the distance between the person and the situation decreases.)
This increasing tendency to avoid the diagnostic situation explains the unreliability of a patient's observations of his own symp- toms and case history. Even when face to face with the doctor they will have a ten- dency towards getting out of the situation by underestimating their own symptoms or concealing their case history. Thus McNemar and Landis obtained a correlation of .50 between patients' reports of frequency of illness and their hospital records. Striking examples of this phenomenon are the persons who lose their symptoms when entering a doctor's office (or a dentist's).
As medicine has become more preventive the necessity to reduce this reluctance has become increasingly important. Medical practitioners in their various' capacities have already taken many steps in this direction.
It is useful to consider the significance of these steps.
As one such step, much has been done to make the public aware of the dire conse- quences that may follow from failure to seek early medical advice. While this measure may be effective in increasing the number of persons who seek early advice it will do so only at the expense of increasing the strength of conflict and hence the associated anxiety. This conflict and anxiety will be reduced only if the unattractive features of the diagnostic situation are diminished.
Of these unattractive features, Barker et al point specifically to those arising from the unfamiliarity of the patient with the diag- nostic and treatment techniques, the expense of medical care, the social attitude towards illness and the pain involved.
Reduction of the anxiety arising from unfamiliarity may be overcome by the physician giving to the patient greater information about the instruments and techniques of diagnosis and treatment and of his program of action; by carrying out the interview under conditions approxi- mating to a normal office of, say, a lawyer.
Recognising that it may be desirable to keep the patient in the dark about some distressing treatment which might cause undue worry or resistance the fact remains that most medical procedures are not in themselves sources of anxiety, but the unknown, poten-
tially painful always is. To "solve" the problem by informing the patient of as little as possible, and then only in general terms, is to ensure a general maximum of anxiety in patients.
In the reduction of the financial grounds of conflict sufficient has been done to indi- cate that "the adequate practice of preventive medicine and treatment of long continuing diseases requires the removal of this financial obstacle". This factor is of even greater importance for the treatment situation. So long as it exists many tubercular and heart disease cases must continue to shorten their lives and endanger the lives of others because they are unable to face costs of their treatment in terms of the loss of wages and social status.
Of the psychological problems entailed in minimising the resistance arising from social attitudes towards illness as a sign of weak- ness, of feminity or of sin, and the resistance arising from fear of pain we merely know sufficient to realise the value of further research.
The above considerations are concerned with the person who believes himself healthy but is anxious about certain unusual symp- toms. Once a person has accepted the fact that he is ill the situation of diagnosis and treatment takes on a very different meaning.
While some anxiety will still be generated by the unfamiliarity of the situation it will be seen as the only means of getting well.
Under these circumstances the patient will frequently seek as much treatment as possible as quickly as possible. The desire to get well, with all that this means in terms of earning power, social life, lack of pain, etc., is often such that where suitable medical treatment is slow, expensive or lacking, patients turn to quacks.
Lastly, there remains unconsidered the person for whom illness is a refuge. Such persons require psychiatric treatment and hence need to be differentiated from those, considered above, for whom medical treat- ment is primary. Three criteria for differen- tiation arise from the differences in the situations they face even when both believe they are sick.
1. The former magnify their symptoms and depreciate the effects of therapy; the latter minimise their symptoms and exag- 2. gerate the effects of therapy.
The prevailing mood of the former will be depressive and pessimistic as com- pared with the optimism of the latter.
3. The symptoms of the former will show considerable variability—as one is cured another will appear. In the latter case, symptoms will be more constant and will be related to the real physical condition of the patient.
By bringing together and systematically interpreting a mass of relatively narrow researches Barker et al have succeeded in creating a basis for the fruitful development of joint medical and psychological research, for the explicit injection of certain simple but valuable psychological principles into medical practice. No attempt has been made to indicate the range of problems over which their analysis extends, but rather to present their views on a single problem so as to reveal the nature of their approach.
Extract from "Bones and all that".
Test Paper 1
ANATOMY — MED. II B.
Pass and honour
(Female students may omit whichever questions they like)
Describe the extra-cranial course and relations of the greater splanchnic nerve.
If you can think of a better course for it, describe that instead.
2. Which is the most pearmeable material:
(a) capillary walls, or (b) brain.
If you have forgotten, write (b).
3. If you were to cut a transverse section through your neck with a cut-throat razor, what would you say? Give details.
4. When you play football, about how many muscles do you use?
(a) 23/4 (b) 50, or (c) 1900?
If (c), enumerate them.
Only footballers should answer this question.
(a) the hairs on Red's head
(b) any other structures that interest you.
6. Describe the nerve supply of the following:
(a) salivary glands (b) adrenal glands (c) heart
in each of the following situations:
(i) after sighting a large meal.
(ii) after eating it in a storm at sea.
(iii) after a session in a parked car.
7. Outline the distribution of skin and fascia in a perfect subject. Use diagrams 8. What would happen if the inferior vena
cava emptied into the stomach? Illus- trate with diagrams. Does it?
9. Do you think Prof. Townsend knows much about female anatomy? Discuss, with examples from your practical work:
(a) in the dissecting room (b) elsewhere (be explicit).
N.B.—Only honours candidates should attempt this question.
10. Give the relations of the kidney and bladder to:
(a) whisky and rhinegold (b) cheap beer.
Extra marks will be given for practical suggestions on how to improve the func- tioning of these organs.
Erratum: For 'say' in question 3, read 'see'.
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