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George Engel was Professor of Medicine and Professor of Psychiatry at the University of Rochester School of Medicine and Dentistry. Trained as an internist, he had criticized the traditional concept of disease being restricted to what can be understood or recognized by a physician [2]. In other words, only the physician could decide if something is a disease and if a patient can be sick. Engel elaborated a unified concept of health and disease [2]: there is no health and no disease, only a dynamic balance between health and disease. Such a view, expressed in 1960, was subsequently elaborated in the biopsychosocial model [3]. Psychosocial factors are a class of etiological factors in every type of disease, but their relative weight may change from one disease to another, from one patient to another, and even from one episode to another of the same illness in the same patient [4]. It is not that certain diseases, defined as ‘functional’, lack an explanation, but rather it is our assessment that is inadequate in most clinical encounters [5].

I spent the summer in his medical-psychiatric unit and the experience was for me an endless source of knowledge and inspiration. One day a psychosomatic consultation was requested from a medical ward. With another medical student, Sam, I went to see the patient. She was a lady in her fifties and manifested what appeared to be an unbearable abdominal pain. Medical work-up could not establish a potential cause. Her condition seemed to be deteriorating and explorative surgery was planned in a couple of days (in 1975, today's minimally invasive explorative procedures were not available). Our job was to interview her and get some preliminary history. Dr. Engel would have come later in the day. We started with some questions, but she appeared to be in great pain. Sam and I agreed that it was probably not the right time and should come back with Dr. Engel, which we did. Dr. Engel immediately got her attention and collaboration. At a certain point during the medical interview, he became interested in a scar the patient had. The lady suddenly brightened up and described a past surgical operation. Dr. Engel asked whether she had undergone other surgical interventions. The lady showed other scars and provided detailed descriptions of each surgery. She seemed to forget about her pain. Sam and I could not understand what was going on. She looked so well, while only hours earlier she was in so much pain. Dr. Engel asked how things were going in her life and she replied that after a very troubled time with a lot of problems in her family things were going reasonably well. When we got out of her room, Dr. Engel told us that the lady had a pain-prone personality and was a surgery addict [6]. When life is treating these patients worst, when circumstances are the hardest, their physical health is likely to be at its best and the individuals are free of pain. When things improve, when some success is imminent, then painful symptoms develop [6]. Sam asked what could be done for these patients. Dr. Engel replied ‘Not much, unfortunately. I will speak with her physician and at least this time we will avoid surgery.’ Sam and I, with our juvenile wish to help, were very dissatisfied by that answer. I thought ‘Maybe one day someone will find the way.’

When the summer was over, I went back to Padova and intended to become like George Engel and be knowledgeable of both internal medicine and psychiatry. In due course, however, I realized that one specialty was already more than I could handle and thus chose psychiatry, the field where most of the psychosomatic researchers came from.