Abstract
I am pleased that the Australian and New Zealand Journal of Psychiatry saw fit to commemorate the contributions of Dr George Engel to medicine on the occasion of his death [1–4]. Australasia, particularly in Melbourne and Dunedin, has been significantly influenced by academics (Ironside, Smith and Singh) and other senior psychiatrists who, directly or indirectly, were inspired by Engel. Somewhat differing from Engel's pessimistic comments to Bruce Singh, I consider his contributions to world medicine significant and likely to be long-lasting. The experiments in medical education at McMaster, Newcastle, Flinders, Monash and Melbourne University medical schools emphasizing doctor–patient interaction directly stem from the Rochester developments of Romano and Engel (the order could arguably be reversed).
My view of Engel is that he was a major contributor to the movement for the scientific humanization of medical practice.
My three years training in psychiatry and liaison psychiatry at Rochester, NY (1957–1960), during what could be called the ‘golden years’ of Rochester psychiatry, constituted for me a renaissance in medical education. I graduated at Melbourne University and trained as a physician at the Royal Melbourne Hospital before proceeding to Rochester for psychiatry and liaison training. Before my Rochester experience, I would describe myself as a competent, narrow, technical craftsman but after coming under the inspiration of Romano and Engel, and I use the word after consideration, I became a much more broadly based professional. Romano and Engel, I believe it appropriate to conjoin them, influenced almost four decades of Rochester graduates. The University of Rochester is one of the pre-eminent medical schools in the US for providing academic leaders in other US medical schools, and the impact of these two persons, and the talented group they gathered around them, will be long lasting.
After leaving Rochester, I spent a year at the Maudsley Hospital in London, and was shocked to find registrars in psychiatry had no supervised interviewing education and were never exposed to their mentors interviewing patients at length. Engel emphasized the importance of the interview in developing a doctor's grasp of the patient's pathos. My view is that the quality of a medical school's education can be assessed by judging how much emphasis is placed on educating medical students to interview with empathy and perception.
For those who question Engel's long-term contribution, I wish to record a teaching practice that I used with medical students at Prince Henry's Hospital, Melbourne (Monash University) for several decades. Directly stemming from my Rochester training, I conducted a weekly session, supervising student interviewing. The patients were from medical wards and considered to have major diagnostic problems. Students were impressed that by empathically encouraging patients to tell their story, they were usually able to resolve the diagnostic issues.
It is said that a way we develop wisdom is through using ourselves as our own control, noting times when we feel well and not so well, and making both periods a learning experience. Engel's identical twin dropped dead of a myocardial infarction at 49 and his father died at 58 of a similar illness. George's long, productive life and his story of how he circumvented premature death, influenced by his analytic insights, constitutes valuable evidence to support his emphasis on the importance of single case studies in developing new appreciations.
Unlike many researchers who only conduct reductionistic research, Engel struggled to do compositionistic research like great figures in medicine as Bernard, Darwin and Freud.
The times in US medicine when Romano and Engel produced their contributions and theoretical developments were special (an affluent, privately endowed medical school allowing generous full-time staff and the absence of ‘managed care’). Australian medical schools will never be so fortunate.
Singh reports on his experience when Engel had fallen out with Romano, sad times indeed because each man enhanced the other. In 1958–1959, Romano spent a sabbatical at the Maudsley, and influenced by Aubrey Lewis' rigour and questioning of psychoanalysis. Soon after, Engel's brother dropped dead and he had a myocardial infarction 1 month from the anniversary of his brother's death. Romano is said to have become more authoritarian after his sabbatical. Engel, presumably sensitive about his precarious health, elected to break with Romano, rather than have frequent arguments with him.
Engel, was the best diagnostician I have observed on a medical or psychiatric ward. He had a wonderful balance of head and heart, was high-minded and morally informed, inspired his staff and fellows; his life was an example for others, and his contributions to medical and psychoanalytic thought were profound. He had a gentle, delightful sense of humour with which he illustrated clinical wisdom. Reference in the four articles is made to his iconoclasm. George was his own man. He distressed certain psychoanalytic colleagues when he was content to remain an Associate within his analytic institute and not push on to full membership. Even though he was an internist by training, other internists felt he was not one of them. Psychiatrists also felt he was not a psychiatrist. But what a wonderfully creative, memorable, lovable man.