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General practitioners are traditionally the front line of support in
any community. Patients expect their doctors to be experts in the full range
of medical disorders. It is somewhat surprising that doctors are also expected
to recognise and know what to do about the often quite vague emotional and
psychological difficulties which patients present. These are conditions
about which the patients may even feel some embarrassment, and which are
often hard to articulate. There is a larger problem, however.

Although many medical schools now include psychology in the curriculum,
students do not accord the subject the same importance as subjects seen
as more relevant to medical practice, for example, anatomy or pharmacy.
And until recently, psychology was not taught at all in medical schools,
with the result that most doctors in practice currently have no training
in common psychological disorder. This is clearly not reflective of the
large number of visits to GPs which are ‘psychological’ in nature. The consequence
of this huge gap in training is that most of what practitioners know about
psychological stress is learnt ‘on the job’, through experience with patients.

This method of learning is fraught with problems: in any trade, it produces
biased perceptions (because of cognitive errors of judgment). In medicine
specifically, ‘rules of thumb’ for diagnosis or treatment tend to develop
and these may be inaccurate or incorrect.

With psychologically distressed patients, medical practitioners are
even more likely to have biased perceptions. Psychological problems are
‘invisible’ and so their severity is hard to calibrate. This leads to a
suspicion that there are pre-existing vulnerabilities: the person is ‘weak’
or ‘just neurotic’, or is a ‘poor coper’ or has a pre-morbid personality
problem. Particular demographic groups may also be seen as more or less
vulnerable to psychological distress. This is a model of ‘social weakness’
and substantially it is based on lay beliefs and biases obtained through
clinical experience. Such beliefs may well lead the doctor, perhaps inadvertently,
to underestimate the distress the patient is experiencing.

Very occasionally, general practitioners are faced with widespread psychological
disorder in the community they serve. After the Lockerbie disaster, for
instance, hundreds of local residents experienced – and continue to experience
– emotional damage. Disasters on the scale of Lockerbie, although thankfully
rare, provide what amounts to a large-scale in-service training programme,
one which challenges preconceptions and ‘rules of thumb’ about vulnerability
and social weakness. Indeed, the local doctors acknowledge that at the outset
they didn’t truly recognise or understand that they were seeing classic
symptoms of post-traumatic stress disorder. And they also expected the ‘strong’
in the community to withstand psychological distress while the ‘weak’ succumbed.

What happened, however, was that the doctors were struck by the degree
to which people from all walks of life and of all ‘types’ were emotionally
and psychologically affected. It was a surprise that working males who,
as a demographic group, are considered more resilient and good at coping
were also emotionally traumatised. Eventually as more residents of Lockerbie
came forward, the striking feature for the general practitioners was that
it was not the weak, or those who had had previous psychological problems,
or other ‘subsections’ of the population who were affected, but everyone,
to one degree or another. There were apparently no groups or types of people
who were immune and, because of this, their models of social weakness had
to be questioned and abandoned. Lockerbie was an exceptional experience,
and a regrettable but valuable clinical lesson.

Lockerbie’s doctors are not the only people whose understanding of psychological
distress has increased. People in the community are generally more aware
of the influence of psychological factors in physical illness; and they
feel more comfortable about discussing such issues with the family doctor.
This is true even for people for whom psychological disturbance (in others)
was almost a joke.

So not only in this extreme situation, but every day, doctors are expected
to possess the same knowledge as a specialist in the area – a psychologist.
They can, however, refer the patient on for psychological treatment, though
this does not always happen: there are lengthy delays in obtaining an appointment,
and many patients are unwilling to be sent elsewhere to see a ‘shrink’.
This may encourage general practitioners to continue to treat disturbed
patients on their own – possibly using sympathy and psy-chotropic medication.
Common sense may also enter the consultation, but unfortunately common sense
tends to be idiosyncratic. Sympathy and appropriate medication to control
the symptoms are often helpful but it is rare for general practitioners
to have time to deal with patients with potentially complex psychological
problems. And some doctors may not really believe in the ‘legitimacy’ of
psychological disorder, and accordingly may fail to treat their patients
appropriately.

One solution would be to give medical students much more training in
psychology. Hand in hand with this would be a recognition that more time
is needed for each consultation – something that is unlikely in the current
political urge to rationalise and reduce services.

An alternative solution undoubtedly also runs counter to what the government
sees as necessary cost-cutting in health care, that of having a psychologist
as an integral staff member in a general practice. This step would have
a number of benefits. Doctors would have something more substantial to rely
on than their own individual inclinations, interests and common sense.

Many patients are resistant to the idea that their illness is ‘psychological’
rather than ‘physical’, and suffer in isolated silence. An immediate referral
within the practice would give the common psychological disorders a face
which is somehow more ‘acceptable’ to the patients, making it part of what
patients might see as ‘real medicine’ rather than making them think that
they are going mad. Treatment for psychological disorder could be dealt
with quickly and avoid the entrenchment of problems brought about by delays
in getting appropriate help.

General practitioners are not psychologists, and rare epidemiological
lessons are not sufficient insurance that patients, generally, are being
dealt with in an informed and unbiased way.

Margaret Mitchell teaches psychology at the Queen’s College, Glasgow.