Richard Smith: What I learnt from brief encounters with a GP whose obituary I’ve just read

richard_smith_2014I find that at age 66 the obituary pages of The BMJ usually include each week at least one person I’ve known. Often the obituaries bring back memories, some exciting some sad. Recently I read the obituary of Mike Courtenay, a general practitioner from Battersea who died aged 94 or 95, leaving seven children, 12 grandchildren, and 7 great grandchildren. (Quite a haul, I thought, for one man.) I spent a few days with Mike and his swashbuckling, leather-wearing, motorbike-riding partner Harry Somebody during a four-week elective as a medical student in 1974. I learnt a remarkable amount from both of them in just a few encounters.

Although I grew up in South London, I was a student in Edinburgh, where the doctors and the medicine were strait laced. Harry taught me in a few hours that you could be a great doctor without wearing a suit and tie and a po-faced manner.

I remember going with either Mike or Harry (I can’t remember which) to see a man with end-stage respiratory failure who was on oxygen at home. He lived high up in a block of council flats and was surprisingly jolly. Mike or Harry talked to him about both sex and dying. I hadn’t before seen a doctor talk about either, but Mike or Harry did it with remarkable ease; and the man spoke comfortably. I was 22 at the time and astonished that an elderly man with respiratory failure had a sex life.

(I remember, perhaps incorrectly, that in our finals two years later we were asked how often people over 60 had sex. The options were once a week, once a month, once a year, never. I think that disgusted by the thought of people over 60 having sex I may have answered never, which I now know to be the wrong answer.)

But the biggest gift that Mike gave me was to take me to a Balint seminar and get me to read Michael Balint’s The Doctor, His Patient, and the Illness, which was published in 1954 (when his was taken to mean his and hers). Mike’s obituary mentions that he was the second president of the Balint Society. Michael Balint was a psychoanalyst from Hungary who escaped Hitler by coming to Britain. He started a practice of supporting general practitioners, which he usually did in groups. GPs would present cases, usually difficult ones, and the GPs and Balint would discuss them, pulling out general lessons, and offering advice on how to manage the patient.

Many of the patients had a wide array of symptoms, but no identifiable physical cause for their symptoms. They often came repeatedly to see the GP and could take a considerable toll of the doctor. (An article years later in the BMJ described them as “heartsink patients,” a term that was quickly declared politically incorrect.) I learnt, firstly, that patients could have serious, disabling symptoms without any physical cause. I learnt as well that constantly referring these patients to different specialist where they had an array of tests did no good for anybody, least of all the patient. An excellent GP might have the confidence to avoid this progression of specialists and tests and help the patient without them.

But perhaps the most important thing I learnt from Mike, the book, and the group (which by this time did not include Balint himself) was the idea of “doctor as drug.” A doctor’s most powerful therapeutic tool is him or herself. By actively listening to patients and “being there” for the patients doctors could often heal without the need for drugs or tests; and even when drugs, surgery, and tests were needed the doctor had the power to enhance their therapeutic power.

I don’t remember ever learning that at medical school.

My final learning from Mike is that you could provide excellent care in dreadful circumstances. One day as I sat with Mike while he consulted rain began to pour through the roof of the surgery. Mike casually put a bucket, and later other buckets, under the leaks without hesitating in the consultation. The patient, concentrating on Mike, didn’t even notice.

I doubt that either Mike or Harry would remember me, and they probably had no idea how much they had taught me in our brief encounters. They no doubt did the same for dozens of students and young doctors. But I’m very grateful to them, and now I wish I’d told Mike before he died.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: None declared.