After the event

November 2014

Up front

Editorial: Picking up the pieces

Volume 43, No.11, November 2014 Pages 743-743

Sarah Metcalfe

The idea of managing patients who have experienced unimaginable horror or suffering can be very daunting. As general practitioners (GPs) we are often the first port of call for people after a significant event or, alternatively, become involved when the patient emerges from the tertiary care system. Part of our role is to help ‘pick up the pieces’, whether the effects have been predominantly physical, psychological or a combination of both. Sometimes the person before you is fragmented, the pieces so fragile and far flung, that putting them back together seems an impossible task. 

Self-care becomes particularly important in these situations and an awareness of any tendency to ‘take on’ the patient’s experience. We all manage this aspect of our work in different ways, be it debriefing in the tearoom over lunch or a more formal discussion with a senior colleague. Balint groups provide an alternative forum. These are regular, structured gatherings of GPs where cases are presented, but it is the relationship between practitioner and patient that is the focus, rather than the medical facts. The group provides the opportunity to debrief, to understand and acknowledge the emotional impact that hearing patients’ stories can have on the doctor, while simultaneously considering the patients’ experience of the encounter. Michael Balint, a Hungarian-born psychiatrist, was the architect of these groups and worked for much of his career, largely with GPs, to more clearly define the therapeutic effects of the doctor–patient relationship.1

When faced with challenging clinical scenarios that are well outside my own life experiences, I feel comforted by the notion of the doctor as the ‘drug’.2 Just listening and acknowledging the patient’s experience may feel inadequate, but the power of the interaction to have beneficial effects, strengthened by our considerable skill and experience in communicating, should not be underestimated.

So it is after the event that there exists potential for healing. It is at this time that GPs have an opportunity to assist our patients and promote recovery: an altogether more hopeful perspective on these often confronting subjects.

In this issue of AFP, Cooper et al3 discuss the most extreme psychological effects of trauma – post-traumatic stress disorder (PTSD). The recent release of the Diagnostic and Statistical Manual of Mental Disorders 5th edition,4 saw some changes in the diagnostic criteria for PTSD. These criteria are outlined by Cooper et al3 to support early recognition of the disorder in general practice, and recommendations are made regarding access to evidence-based specialist management.

Traumatic brain injury presents a complex interplay between the physical and psychological, which can be devastating for patients and carers alike. Jagnoor and Cameron5 draw on the best available evidence for the more immediate and longer term management of this diverse group of patients, highlighting likely complications and recommendations for assessing carer burden: an important consideration for GPs managing these patients and their families.

Refugees and asylum seekers are never far from the mainstream media headlines in recent times, and provision of healthcare to this population may seem specialised and somewhat removed from ‘regular’ general practice. Certainly, it is a smaller group of practitioners who deliver more immediate post-arrival care, but patients who have had refugee-like experiences are very likely to be among the patient populations of most practitioners and their experiences may well remain relevant across the lifespan. Phillips6 helps us to understand the healthcare access landscape for various groups of recently arrived refugees and provides practical examples of clinical contexts in which refugee-like experiences may be relevant to the way in which we deliver care to this population.

Family violence is another topic that some GPs may feel is not relevant to their practice, but the reality is that this problem frequently goes undetected. Forsdike et al7 emphasise the importance of GPs being aware of the potential for family violence and providing opportunities for patients to disclose, as well as strategies for supporting them if they do.

We hope this issue can help illuminate some of the darker corners of the human experience and give GPs the confidence to be part of recovery, even if just by asking and listening.


  1. Lakasing, E. Michael Balint – an outstanding medical life. Br J Gen Prac 2005;55:724–25.
  2. Balint, M. The doctor, his patient and the illness. Edinburgh: Churchill Livingstone, 1992.
  3. Cooper J, Metcalf O, Phelps A. PTSD – an update for general practitioners. Aust Fam Physician 2014;43:754–57.
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Arlington: American Psychiatric Publishing, 2013.
  5. Jagnoor J, Cameron ID. Traumatic brain injury – support for injured people and their carers. Aust Fam Physician 2014;43:758–63.
  6. Phillips C. Beyond resettlement: long-term care for people who have had refugee-like experiences. Aust Fam Physician 2014;43:764–67.
  7. Forsdike K, Tarzia L, Hindmarsh E, Hegarty K. Family violence across the life cycle. Aust Fam Physician 2014;43:768–74.


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