Introduction

At pre-clinical, clinical and postgraduate levels, medical training could incorporate teaching on: the concept of straightforward and complicated clinical transactions; an understanding of the influence of personality and unconscious, as opposed to conscious, motivation of doctor and patient in their clinical interaction; the influence of past relationships with authority figures upon the attitudes and behaviour of doctor and patient as they transact; the influence of the psychological and social context (including the clinical setting itself) of doctor and patient on the clinical transaction; and the use of transaction and systems windows, as well as other interventions. This is because, particularly in primary care practice, it has long been acknowledged that diagnosis should be couched not only in physical but in psychological and social terms (Royal College of General Practitioners, 1972) and that the psychological component of the consultation is fundamental (Pendleton, 1983).

The work of Michael and Enid Balint (see Balint, 1957; Balint and Norrell, 1973), emphasising a deeper level of diagnosis, has influenced the practice of many doctors and, increasingly, doctors’ attitudes to their patients form an important discriminator between ‘good’ and ‘bad’ doctors (Kilpatrick, 1993). It has also been recognised that doctors’ interventions exert a psychological effect on patients that can influence the outcome of the clinical transactions not only in the short term but also in the long term (Freeling and Harris, 1984).