Abstract
Objective
To provide a review of my personal exposure to the Medical Psychiatric (Medical Psy) Liaison Group in Rochester during the tenure of a National Health of Medical Reseach Council Travelling Fellowship in the Clinical Sciences from June 1975 to March 1977.
Method
A personal reminiscence and review of a number of papers by George Engel.
Results
The Medical Psy Liaison Group had been developed by George Engel in 1946. My experiences were coloured by the fact that Engel had recently stepped down as Head and tensions in the structure and function of the group were obvious.
Conclusion
My personal experience with Engel, the Medical Psy Liaison Group, Rochester psychiatry and my exposure to American psychiatry all had major influences on my subsequent career but perhaps not in a way that I might have expected when I went to Rochester.
In this paper I relate my experiences as a Fellow in the Medical Psychiatric (Medical Psy) Liaison Program developed by George Engel at the University of Rochester from 1946 onwards, during the period 1975 to March 1977, and its effect on my career.
This paper, written in response to the Editor's request to acknowledge the death of George Engel in November 1999, is part of a symposium on his contributions to psychiatry. Some of the observations I will make are by necessity personal, some may well be unexpected, and some will reveal my clear ambivalence towards my experiences in Rochester. His contributions are well known and others will deal with them more adequately than I, both within this symposium and elsewhere. Being familiar with Engel's willingness to reveal his innermost feelings and his ambivalence in reflecting on his own life have emboldened me! [1–3]
The context
Let me put the experience into perspective. The programme at Rochester had attracted several Melbourne fellows prior to my visit. One participant in the 1950s was Foundation Professor of Psychological Medicine, Wallace Ironside [4,5]. A stream of fellows had been inspired to go to Rochester, some to do a full psychiatric training, others to enter the Medical Psy Program (MPP). In 1970, after my internship, I entered physician training at the Royal Prince Alfred Hospital (RPAH) and at the insistence of Ross Kalucy, then Clinical Superintendent, I reluctantly completed a rotation in the psychiatric unit, a ‘short straw’ term in the physician training scheme.
I was struck by the breadth and depth of intellect of the then Head of the Department of Psychiatry David Maddison. I decided to take up psychiatric training in 1972 while completing my physician exams, much to the distress of friends and despair of family. I completed the three year training in 1974. After discussion with Dr Bernie Hughson, then a staff specialist at RPAH, I decided to capitalize on my membership of the Colleges of Physicians and Psychiatry by developing an academic career at the interface between medicine and psychiatry, then known as ‘psychosomatic medicine’ [6].
A National Health of Medical Reseach Council (NH & MRC) Travelling Fellowship in the Clinical Sciences, offered a two year overseas stint and a year in Australia in psychosomatic medicine (Professor Issy Pilowsky chaired the selection panel). Having passed the MRANZP examination in 1975, I commenced my two year Fellowship in Rochester MPP at Strong Memorial Hospital. I had opted for this programme since it was then regarded as the premier centre for research and education at the interface of medicine and psychiatry. The programme's title made this explicit.
The Rochester experience
My family and I were met at the airport by Norman Poynter, a Monash graduate who had completed his psychiatry training in Rochester and was doing psychoanalytic training. I soon learnt two other Fellows were in the programme, a gastroenterologist, Douglas Drossman (now Professor of Medicine and Psychiatry at the University of North Carolina), and a clinical psychologist, Gary Morrow.
During my second year, Doug moved to an academic position but a group of primary care physicians; Jack Resnik, Norm Yellig and Jerry Reisman; an internist, Dennis Novack and psychiatrists Moshe Torem, Herb Ochitill and Sunil Nasr arrived.
The Medical Psy Unit occupied a group of offices midway between the psychiatric wing named after a benefactor, but known as the Romano Wing, after Emeritus Professor John Romano (he had come from Cincinnati in 1946 with George Engel to establish the department at the Strong) [7]. Its position symbolized its orphan status, neither part of psychiatry nor fully integrated into medicine. This should have been a warning to me!
My first encounter with Engel lives in my mind as befits an occasion when one comes into contact with a celebrated, larger-than-life figure. He was a small, wiry man, balding, in his sixties, with a warm grin and friendly demeanor. Symbolically, he had an office separate from others in the Medical Psy group. It soon became apparent that he had stepped down as its head and designated Art Schmale as the titular director. Other longstanding members were Bill Greene, Dave Tingling and Don Klein. Sandy Meyerowitz had become Dean of the medical school, while two recruits were Mac Lipkin and Joe Glaser, a gastroenterologist, both brash and bold internists and typically American in style and approach. Initially I was allocated to Engel for supervision, but following an interview with him, he discovered that I had ‘crossed’ the divide (vide infra) and rapidly switched to take on my internist colleague, Dr Drossman. I was assigned to the ‘absent’ Dean, Sandy Meyerowitz, the only psychiatrist in the group. Sandy was a psychoanalyst with an insightful attitude to the human condition. Tragically, he died of cancer during my second year. Tony Labrum and Marianne Friederich were additional faculty members with joint appointments in the MPP and Department of Obstetrics and Gynaecology.
I soon learned that, as with many eminent revered figures, Engel was regarded ambivalently by some of his colleagues (The prophet without honour in his own homeland'). Engel's separation from the group was actual as well as geographical. Bill Greene, who had been one of his first proteges, was no longer on speaking terms with him. Some tensions were a consequence of the transition to Schmale's leadership. Most disturbing to me (and others) was the fact that Engel, who had come to Rochester as a result of the influence of John Romano, had fallen out with him; they no longer communicated. This was poignant since Romano had an office immediately below that of Engel (he occupied it as a retiree in deference to his emeritus status and influence he continued to exert on American psychiatry). Many were still grieving the loss of his leadership. Lyman Wynne, his successor, and a recruit from NIMH bore little resemblance to Romano in inspirational style.
It did not take long to discover Engel's ambivalence to psychiatry, which may have been reflected in his relationship with Romano. Although respected internationally as a psychiatrist, Engel saw himself as a ‘card carrying’ internist. He was Board certified in that speciality but only Board eligible in psychiatry. Since the early years of the MPP, he had surrounded himself mainly with internists and later, with obstetricians, gynaecologists and primary care physicians. The only psychiatrist on my arrival was my own supervisor [8,9].
It soon became clear that Engel also preferred internists as Fellows. Most of the doctors who had passed through the Program in the first decade were internists. The reasons for Engel's ambivalence to psychiatry soon emerged. He saw himself as a model of the physician who could bring the same scientific rigor that he had learnt in the laboratory and in clinical medicine to behavioural science, whereby he had discovered an intrinsic but neglected part of medicine [10].
For Engel to be regarded as a psychiatrist was to be perceived as him having crossed the divide between medicine and psychiatry. He believed that the MPP would act as the vehicle by which other internists would follow his lead and also traverse this divide. He had a broad view of the physician's role and posited that he or she should be capable of incorporating a psychosocial dimension into their everyday clinical work [11]. He synthesized these ideas as ‘the biopsychosocial (BPS) approach’. Although embraced more readily by psychiatry than other branches of medicine, it was not devised for it but for medicine overall, and internal medicine in particular.
In conversations with Engel he expressed his disappointment that the BPS approach had not ‘swept the country’. In fact, it was evident that internal medicine was moving in the opposite direction, becoming more technical with the immense growth in investigatory techniques. He lamented to me ‘If I'd known just how hard this would be, I would have concentrated on something else!’. He also speculated on why the BPS approach had been so hard to implement – the socialization processes, essential to becoming an internist or a psychiatrist, had a powerful effect on all who entered the respective speciality training programs and different personalities may have been attracted to them [12].
I also noted Engel's ambivalence to conventional scientific research. Although his early work had applied standard methods, albeit descriptive (e.g. on fainting [13] and delirium [14]), he had become enamoured with qualitative research and by the single case approach. Monica, the child with oesophageal atresia corrected by surgery, whom he had seen on her first admission and was still following up 40 years later was his pride and joy. He had an analyst's perspective on how much could be learnt from a single patient provided one had the right ‘scientific attitude’. He obviously fell foul of Popper's dictum that science proceeded not by creating hypotheses but by refuting them [15–17]. As a result of this influence I undertook a personal analysis while at Rochester.
Engel supported my attempt to initiate research in order to achieve a higher degree and helped me design a study to examine the role of sadness in diabetes. The effect of a sad film (a documentary on the Aberfan mine disaster of which Engel was particularly fond and used to demonstrate grief and loss to medical students) on growth hormone was the main interest since he considered it the hormone of ‘conservative withdrawal’ and relevant in the control of diabetes. However, with the study completed, he discouraged me from publishing, perhaps because it did not confirm his hypothesis. As he said: ‘I have filing cabinets full of research results which I have never published because the studies weren't right’. The data, meticulously collected on many a freezing Rochester morning, on the experimental (Aberfan movie) and control condition (travelogues) with eight stable diabetics temporarily taken off their insulin, still sits in a cabinet drawer, in deference to him.
Engel and Consultation–Liaison Psychiatry (CLP)
It was during my period in Rochester that I realized that psychosomatic medicine, in particular CLP, was floundering. This was reinforced by interaction with other psychiatrists working in the area and attendance at meetings of the American Psychosomatic Society in 1976 and 1977. The subspeciality of CLP was in trouble as Government grants for training instituted in the 1960s dried up. The question of who was to pay for CLP also emerged as a major issue. Was it psychiatry's role to offer CLP or was it medicine's role to pay for it? Despite advocates on both sides, neither speciality was willing to fund CLP.
Extraordinarily (to me), a CLP service was run by the Department of Psychiatry in addition to the MPP. Engel's view on this was revealing, he saw the former as consulting about the psychiatric problems of medical patients or contributing to the management of psychiatric patients on the medical wards. In contrast, the MPP fellows dealt with the psychosocial dimension – coping, adaptation and adjustment – as it affected the medical patient, and offering staff help to incorporate the psychosocial into everyday clinical work. Engel was brilliant at bridging the gap ‘to observe him interviewing was a privilege, particularly with the pain patients’ [18] or with those who have ‘given up’ [19]. He was also adept at challenging the audience by focusing on psychosocial aspects and the psychosomatic understanding that his particular insights could offer. On the other hand, when he interviewed a patient in the presence of a psychiatric audience he would focus on medical aspects (with which they were less familiar) and demonstrate knowledge of physical aspects illuminated by psychiatric insights. Perhaps because I had completed my physician and psychiatrist training just prior to Rochester, his approaches with different groups were so clear and his mastery of both bodies of knowledge so striking.
Engel and my subsequent career
The insights I gained during my time at Rochester had a profound and paradoxical effect when I returned to Australia. My experience coupled with my discussions with colleagues in the Department of Psychiatry at Rochester and elsewhere, convinced me that American psychiatry was shifting from an era of psychoanalytic dominance to an emphasis on diagnosis and greater scientific attention (primarily biological) to the major disorders. This came to fruition in the 1980s after DSM–III's publication, but the background work began in the mid 1970s stimulated by the work of Guze and Robins and the ‘St Louis school’ [20].
I returned to Australia in 1977, feeling that despite all academic psychiatric centres being located in general hospitals and many highlighting CLP, opportunities were limited. I presented this view at a conference to celebrate the opening of the Monash Medical Centre, which received a predictable response from the Prince Henry's Hospital team who, influenced by Wallace Ironside, were the chief exponents of Australian CLP.
John Romano, a major figure in Rochester had influenced me in this view [7]. By the time I came there, he was limited to conducting rounds at the Rochester State Psychiatric Hospital, a vast asylum a kilometre up the road but a thousand light years away in terms of its patient population and approach to treatment, compared to what was practised in the Strong Memorial Hospital. Staff, predominantly foreign trained, looked after institutionalized patients in abysmal surroundings. Romano provided brilliant teaching to a group whose ability to comprehend the BPS approach was limited. On the other hand, I was enthralled to see him draw out from even deteriorated schizophrenic patients key elements of their life stories. He taught me that the life history method of Adolph Meyer was applicable to any patient; in doing so the patient became more real and alive, and potentially more able to be worked with. Engel was undoubtedly, in his usual insightful way, right–I had ‘crossed the divide’.
The parlous state of CLP together with the post-Kennedy emphasis on community psychiatry (which was not the community psychiatry we know today but rather, committed mental health professionals doing whatever they thought was most appropriate ‘to promote the mental health of their communities'), the certainty that the asylum system was not viable and an emphasis on Popperian ‘science’ as opposed to psychoanalytic methods, convinced me that we were entering a new era in which patients from the backwaters would shift onto centre stage as a prime concern of psychiatry. Meanwhile the non-psychotic and psychiatry of the medically ill would move to the periphery. Therefore, I planned my career to ensure that I could contribute to this transition. After completing the necessary ticket to academia–a research degree (a PhD on psychological aspects of the control of breathing)–I applied for the chair at the Royal Park Hospital in Melbourne, rather than one based at Prince Henry's hospital when both were advertised by Monash University in 1983 following Wallace Ironside's retirement. My decision was disconcerting to many colleagues in the light of my training, interests and stint in Rochester.
I then used that base to establish and codirect, with Professor David Copolov from the Mental Health Research Institute, Australia's first NH & MRC Schizophrenia Research Unit during the decade 1986–1995 as well as to recruit academics to focus on psychotic disorders, the main focus of the public mental health system. However, Engel's influence was pervasive. I continued to work in CLP at the Alfred Hospital and applied Engel's teaching methods for medical students and psychiatric trainees at the University of Newcastle and at the Alfred, Royal Park and Royal Melbourne Hospitals. The most successful feature was the ‘five-minute interview’ – an opportunity to apply his methods of observation to the initial phase of an interview with patients, where their style of presenting themselves and their history was analysed. I also developed a half-hour interview where trainees were expected to gain as much information as possible and generate plausible hypotheses about their clinical states. Following the ‘discipline of putting the material together’ based on such limited observation, a colleague with full knowledge of the patient would provide the ‘answers’ so that other trainees could see how right or wrong they had been in their hypotheses [21].
Conclusion
What conclusions can I draw about Engel's great ‘experiment’? He articulated his hope very clearly in an early paper on the MPP:
The student who is being urged to deal with his patient ‘as a whole’ is actually treated to a spectacle that it takes at least two experts, an internist and a psychiatrist to do the job that students are being asked to accomplish on their own. It is little wonder that many students exposed to this type of joint teaching remain cynical in their attitude towards comprehensive medicine. The factor of identification with the model physician, which is so important to the student's learning process, is blocked by the reality that there is no figure that is able to comprehend the patient in his or her totality [8].
Engel saw himself as this model physician and believed that he could train other physicians and (more reluctantly) psychiatrists to play this role. For a while it appeared he was ‘on a winner’ but then medicine and psychiatry both changed and to complete his quote: ‘in the end the student identifies with either the psychiatrist or the internist and only rarely with the still abstract symbol of the comprehensive physician.’ If, as Walter Lippman [22] put it, ‘The final test of a leader is that he leaves behind him in other men the conviction and will to carry on’, then judged by that criterion the MPP can be seen to have been a limited success. Although Engel left behind dedicated disciples [23] around the world, they form small groups who struggle in isolation to carry his message to an economically rational and sceptical world of medical practitioners. But perhaps there could only be one Engel driven by a narcissistic belief in his own ‘specialness’, amply revealed in his autobiographical papers [24]. Along with others in Rochester, I was never convinced that he wished the MPP to outlive him.
What no one can deny is that he did leave a towering edifice, the BPS approach, and will be remembered by many in the way I believe he saw himself; namely a ‘medical Darwin’. He created a way of looking at the human condition in health and illness that many others may have seen and appreciated, but it was he alone who thought what no one had thought before in terms of bringing it all together in a simple yet elegant approach of which he became the most articulate advocate in his time. Ironically, psychiatry carries his banner with the most fervour. I suspect he would have preferred it to have been medicine.
Postscript
I only saw Engel once again when I gave a grand round in 1982 on the subject of my PhD thesis. He did not attend, but at his invitation, I visited him at home. He had aged considerably (his wife had been ill) but his warm grin and his quick sense of humour were familiar. He had prepared a simple lunch (he was alone in the house) which we shared and he told me about various Rochester medical and psychiatric personalities and their doings since I had left, his decreasing involvement in the medical centre and the numerous invitations to speak he had received from around the country and overseas, many of which he had declined because of failing health.
He showed a great interest in my career and in particular in the radical ideas on medical education which David Maddison had brought to the medical school at Newcastle and how we were incorporating his BPS approach throughout the curriculum (a task I am implementing again in the new University of Melbourne curriculum). When I rose to leave, he ushered me out with great warmth and affection and wished me well for the future, which he assured me would be ‘impactful’. As I walked out into the gloomy winter afternoon I knew I would be unlikely to see him again. I felt privileged to have known him and to have been ‘in the eye’ of one of the leading figures in medicine and psychiatry of our time.