Primary Care/Primarily Caring (IV)

If it is little known in medical circles that World War II “made” American psychiatry, it is even less well known that the war made psychiatry an integral part of general medicine in the postwar decades.  Under the leadership of the psychoanalyst (and as of the war, Brigadier General) William Menninger, Director of Neuropsychiatry in the Office of the Surgeon General, psychoanalytic psychiatry guided the armed forces in tending to soldiers who succumbed to combat fatigue, aka war neuroses, and getting some 60% of them back to their units in record time.   But it did so less because of the relatively small number of trained psychiatrists available to the armed forces than through the efforts of the General Medical Officers (GMOs), the psychiatric foot soldiers of the war.  These GPs, with at most three months of psychiatric training under military auspices, made up 1,600 of the Army’s  2,400-member neuropsychiatry service (Am. J. Psychiatry., 103:580, 1946).

The GPs carried the psychiatric load, and by all accounts they did a remarkable job.  Of course, it was the psychoanalytic brass – William and Karl Menninger, Roy Grinker, John Appel, Henry Brosin, Franklin Ebaugh, and others – who wrote the papers and books celebrating psychiatry’s service to the nation at war.  But they all knew that the GPs were the real heroes.  John Milne Murray, the Army Air Force’s chief neuropsychiatrist, lauded them as the “junior psychiatrists” whose training had been entirely “on the job” and whose ranks were destined to swell under the VA program of postwar psychiatric care (Am. J. Psychiatry, 103:594, 1947).

The splendid work of the GMOs encouraged expectations that they would help shoulder the nation’s psychiatric burden after the war. The psychiatrist-psychoanalyst Roy Grinker, coauthor with John Spiegel of the war’s enduring  contribution to military psychiatry, Men Under Stress (1945), was under no illusion about the ability of trained psychiatrists to cope with the influx of returning GIs, a great many “angry, regressed, anxiety-ridden, dependent men” among them (Men Under Stress, p. 450).  “We shall never have enough psychiatrists to treat all the psychosomatic problems,” he remarked in 1946, when the American Psychiatric Association boasted all of 4,000 members.  And he continued:  “Until sufficient psychiatrists are produced and more internists and practitioners make time available for the treatment of psychosomatic syndromes, we must use heroic shortcuts in therapy which can be applied by all medical men with little special training” (Psychosom. Med., 9:100-101, 1947).

Grinker was seconded by none other than William Menninger, who remarked after the war that “the majority of minor psychiatry will be practiced by the general physician and the specialists in other fields” (Am. J. Psychiatry, 103:584, 1947).  As to the ability of stateside GPs to manage the “neurotic” veterans, Lauren Smith, Psychiatrist-in-Chief to the Institute of Pennsylvania Hospital prior to assuming his wartime duties, offered a vote of confidence two years earlier.  The majority of returning veterans would “present” with psychoneuroses rather than major psychiatric illness, and most of them “can be treated successfully by the physician in general practice if he is practical in being sympathetic and understanding, especially if his knowledge of psychiatric concepts is improved and formalized by even a minimum of reading in today’s psychiatric literature”  (JAMA, 129:192, 1945).

These appraisals, enlarged by the Freudian sensibility that saturated popular American culture in the postwar years, led to the psychiatrization of American general practice in the 1950s and 60s.  Just as the GMOs had been the foot soldiers in the campaign to manage combat stress, so GPs of the postwar years were expected to lead the charge against the ever growing number of “functional illnesses” presented by their patients (JAMA, 152:1192, 1953; JAMA, 156:585, 1954).  Surely these patients were not all destined for the analyst’s couch.  And in truth they were usually better off in the hands of their GPs, a point underscored by Robert Needles in his address to the AMA’s Section on General Practice in June of 1954.  When it came to functional and nervous illnesses, Needles lectured, “The careful physician, using time, tact, and technical aids, and teaching the patient the signs and meanings of his symptoms, probably does the most satisfactory job” (JAMA, 156:586, 1954).

Many generalists of the time, my father, William Stepansky, among them, practiced psychiatry.  Indeed they viewed psychiatry, which in the late 40s, 50s, and 60s typically meant psychoanalytically informed psychotherapy, as intrinsic to their work.  My father counseled patients from the time he set out his shingle in 1953.  Well-read in the psychiatric literature of his time and additionally interested in psychopharmacology, he supplemented medical school and internship with basic and advanced-level graduate courses on psychodynamics in medical practice.  Appointed staff research clinician at McNeal Laboratories in 1959, he conducted and published  (Cur. Ther. Res. Clin. Exp., 2:144, 1960) clinical research on McNeal’s valmethamide, an early anti-anxiety agent.  Beginning in the 1960s, he attended case conferences at Norristown State Hospital (in exchange for which he gave his services, gratis, as a medical consultant).  And he participated in clinical drug trials as a member of the Psychopharmacology Research Unit of the University of Pennsylvania’s Department of Psychiatry, sharing authorship of several publications that came out of the unit.  In The Last Family Doctor, my tribute to him and his cohort of postwar GPs, I wrote:

“The constraints of my father’s practice make it impossible for him to provide more than supportive care, but it is expert support framed by deep psychodynamic understanding and no less valuable to his patients owing to the relative brevity of 30-minute ‘double’ sessions.  Saturday mornings and early afternoons, when his patients are not at work, are especially reserved for psychotherapy.  Often, as well , the last appointment on weekday evenings is given to a patient who needs to talk to him.  He counsels many married couples having difficulties.  Sometimes he sees the husband and wife individually; sometimes he seems them together in couples therapy.  He counsels the occasional alcoholic who comes to him.  He is there for whoever seeks his counsel, and a considerable amount of his counseling, I learn from [his nurse] Connie Fretz, is provided gratis.”

To be sure, this was family medicine of a different era.  Today primary care physicians (PCPs) lack the motivation, not to mention the time, to become frontline psychotherapists.  Nor would their credentialing organizations (or their accountants) look kindly on scheduling double-sessions for office psychotherapy and then billing the patient for a simple office visit.  The time constraints under which PCPs typically operate, the pressing need to maintain practice “flow” in a climate of regulation, third-party mediation, and bureaucratic excrescences of all sorts – these things make it more and more difficult for physicians to summon the patience to take in, much less to co-construct and/or psychotherapeutically reconfigure, their patients’ illness narratives.

But this is largely beside the point.  Contemporary primary care medicine, in lockstep with psychiatry, has veered away from psychodynamically informed history-taking and office psychotherapy altogether.  For PCPs and nonanalytic psychiatrists alike – and certainly there are exceptions – the postwar generation’s mandate to practice “minor psychiatry,” which included an array of supportive, psychoeducative, and psychodynamic interventions, has effectively shrunk to the simple act of prescribing psychotropic medication.

At most, PCPs may aspire to become, in the words of Howard Brody, “narrative physicians” able to empathize with their patients and embrace a “compassionate vulnerability” toward their suffering.  But even this has become a difficult feat.  Brody, a family physician and bioethicist, remarks that respectful attentiveness to the patient’s own story or “illness narrative” represents a sincere attempt “to develop over time into a certain sort of person – a healing sort of person – for whom the primary focus of attention is outward, toward the experience and suffering of the patient, and not inward, toward the physician’s own preconceived agenda” (Lit. & Med., 13:88, 1994; my emphasis).  The attempt is no less praiseworthy than the goal.  But where, pray tell, does the time come from?  The problem, or better, the problematic, has to do with the driven structure of contemporary primary care, which makes it harder and harder for physicians to enter into a world of open-ended storytelling that over time provides entry to the patient’s psychological and psychosocial worlds.

Whether or not most PCPs even want to know their patients in psychosocially (much less psychodynamically) salient ways is an open question.  Back in the early 90s, primary care educators recommended special training in “psychosocial skills” in an effort to remedy the disinclination of primary care residents to address the psychosocial aspects of medical care.  Survey research of the time showed that most residents not only devalued psychosocial care, but also doubted their competence to provide it (J. Gen. Int. Med., 7:26, 1992; Acad. Med., 69:48, 1994).

Perhaps things have improved a bit since then with the infusion of courses in the medical humanities into some medical school curricula and focal training in “patient and relationship-centered medicine” in certain residency programs.   But if narrative listening and relationship-centered practice are to be more than academic exercises, they must be undergirded by a clinical identity in which relational knowing is constitutive, not superadded in the manner of an elective.  Psychodynamic psychiatry was such a constituent in the general medicine that emerged after World War II.  If it has become largely irrelevant to contemporary primary care, what can take its place?  Are there other pathways through which PCPs, even within the structural constraints of contemporary practice, may enter into their patients’ stories?

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

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One response to “Primary Care/Primarily Caring (IV)

  1. Charles R. Davis Jr.

    Your father was my family doctor growing up. My parents had a Gentleman’s farm on RT 113 and Your father used to make house calls in those days. I remember I was sick with the flu and he came over and gave me Medicine and took my temperature and looked me all over. and had the office call the next day to make sure I was ok. The old days are dead and gone.— Your Dad was a great Dr.

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