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The need for a transitional model: a challenge for biopsychosocial medicine? *.

Malaise pervades the secret meeting places of the biopsychosocial community, a sense that a concept of overwhelming appeal has proved inordinately difficult to apply. Some of the problems are intrinsic to the expanded model--difficulty in teaching it or applying it selectively under pressure and the lack of a nosological glossary. The leading cause of its apparent unacceptability may be extrinsic--the feeling among family doctors that talents with which one must be born are required for practicing successfully within its framework. The need for a transitional model is thus suggested and, in this light, the advantages of the split model, recently identified and, unwittingly, widely taught, are considered.

Over a decade has passed since George Engel challenged biomedicine by calling for a broadening of our understanding of the human experience of disease (Engel, 1977). His signal contribution consisted of sharpening the focus on the limits of the biomedical model and of pointing out that its domination of Western thinking about disease and health care comprises a folk concept that shapes the public's expectations in addition to governing the way doctors practice. Engel's place in the history of ideas is secure, and most educated people would subscribe to his approach. However, there are growing signs of malaise in the biopsychosocial community, expressed eloquently and with poignance at a recent conference in Wickenburg, Arizona. The title of Engle's paper, delivered there before a distinguished gathering of educators, clinicians, philosophers, and social scientists, is instructive: "How Much Longer Must Medicine's Science Be Bound by a Seventeenth Century World View?" (Engel, 1988)

Other participants took great pains to show that humanistic medicine can also be scientific, indeed, that concentrating on the abstractions of biomedicine to the exclusion of the "the lived world" is unscientific (Schwartz & Wiggins, 1988). Buy why is the point still belabored? Reading the papers that were the basis for discussion or that emerged from the conference for which the mandate was to redefine medicine's task, one gets the feeling that we are bogged down--that something has gone wrong--and that putting a concept as intellectually compelling as the biopsychosocial model to work in everyday practice is proving inordinately difficult. It is easy to impute the fault to intrinsic factors: (Antonovsky, 1979) applied biopsychosocial science is not easily taught, (Balint, 1973) it is hard to apply selectively under conditions of stress, and (Barsky, 1979) it lacks a nosological glossary that can help the ordinary doctor feel comfortable with it. However, there is an extrinsic factor that has not been considered--could Engel not have gone too far? Perhaps the fault lies with those of us who are engaged daily in the care of patients, and the model is simply too good for present standards of practice. Perhaps we require a transitional framework to tide us over until new methods of education and the glossary have come into being.

In what ensues, I shall keep to the first person to avoid implying that scientific proof is being furnished to the effect that what is written is necessarily generalizable. I shall expose my own weaknesses but not conceal a gut feeling that I am talking about a bind in which many family doctors find themselves today, and that "we" or "us" would do as well.

I am committed to the biopsychosocial approach; it appeals to me intellectually and emotionally, but I do not have the stamina to apply it to every one of the 35 patients who may attend a single clinic session. In spite of having read much of the requisite literature, I do not always know "how to be" biopsychosocial, and I often end the day with a feeling that all the people who needed a broader diagnosis received amoxycillin or a nonsteroidal anti-inflammatory drug and those who got a bit more of my time walked out of the room feeling understood but, possibly, with undiagnosed hypothroidism. As a result, although I enjoy practicing medicine, I often do so with a bad conscience.

The quandary is not new. A generation before Engel, Balint referred to the moment of truth between patient and physician, when a correct interpretation can keep the former from settling down within the lifelong confines of illness, as "the flash" (Balint, 1973). To some members of his original group, this highly subjective revelation, experienced only by people with special sensibilities, stood for the difficulty in moving a conceptual framework that explained brilliantly what took place between them and their patients to a point where it might have a therapeutic impact. The implied criticism is quantitative; how can it even begin to assuage all the misery that crowds our waiting rooms?

That Engel's model needs to be applied selectively, a point he himself concedes, and that this is no easy matter is shown by the following incident. A woman of 50 came to see the duty doctor at an academic family-medicine clinic because, as she stated repeatedly, she was feeling very unwell. She gave no further details and seemed incapable of being more specific. The doctor, constrained by his biopsychosocial orientation and the tragic look on the woman's face to explore her milieu, elicited a number of reasons for unhappiness at home and expressed his sympathy, for which the patient seemed genuinely grateful. The physical examination, except for a pulse rate of 100/minute, was unrevealing, and the doctor, with a growing sense of frustration over this supposedly urgent encounter, resorted in desperation to a "review of systems." This review led directly to the fact that over the course of 48 hours, the patient had passed a number of loose, tarry stools indicating gastrointestinal bleeding. It is unlikely that the biopsychosocial approach did her much harm but it did delay, for 25 minutes on a busy day, requisite and definitive action to deal with her blood loss, that is, calling an ambulance and starting her on an intravenous.

We are only at the beginning of compiling the nosological glossary that will make it possible for us to work comfortably within the biopsychosocial framework. The new terms must encompass common denominators among patients in recognizable situations. When a chart is being reviewed during rounds, the words lassitude, diarrhea, pigmentation, vomiting, hyponatremia, and eosinophilia will conjure up a picture of Addison's disease in the minds of the discussants, even to the point where they are able to envision the expected histology of the adrenal glands, which, to all intents and purposes, are invisible to them. Thus, in Plato's terminology, the phenomena that constitute the symptoms, signs, and laboratory findings evoke the noumenon we name the disease. The latter has a reality entirely apart from any given patient suffering from it and can serve as a basis for communication, consultation, prognosis, and treatment.

In the psychosocial sphere, on the other hand, practice and, for that matter, research, are hindered by the need for lengthy presentations to convey the patient's situation. There are as yet no equivalents to unsophisticated but useful biomedical diagnoses, such as low back pain or gastroenteritis, though many psychosocial phenomena are no less common.

Family medicine, the youngest of the social sciences, has felt this lack most keenly. Dixon, reporting on a seemingly futile exercise in data gathering and recording, expressed his frustrations with a conventional diagnostic index thus: "What I recorded, but did not 'see', were upper respiratory infections, hypertension, anxiety states, general malaise; what I saw, but could not record, were people, their friends and families, with problems" (Dixon, 1983).

To summarize, what is being suggested here is that the transition from a biomedical approach to the biopsychosocial model is not simply a question of "legislation" or the promulgation of a manifesto. It is not even the logical and inevitable outcome of the uncovering of new facts. Rather, it is a gradual process that includes the accrual of useful terms that are essentially qualitative but can, at times, lend themselves to quantification. Some of them are already at hand: the family APGAR (Smilkstein, 1978), the sense of coherence (Antonovsky, 1979), the recognition of clinical reality as being culturally constructed and pluralistic (Kleinman, Eisenberg, & Good, 1986), and the unifying concept of a "central elaboration of a peripheral stimulus" in keeping psychogenic and physical pain on the same level of understanding (Barsky, 1979), to mention a few.

THE SPLIT BIOPSYCHOSOClAL MODEL

Doherty, Baird, and Becker (1986) identified a third framework within which family medicine is practiced: the split model. On the whole, they speak of it unapprovingly but concede that it is probably more widely applied and taught than its predecessors. I do not believe, as they imply, that family doctors have adopted the split model by default or that they adhere to it because they do not wish to stray too far from being "real doctors." I accept the accusation that my practice reflects the split model, but I vehemently deny that this has anything to do with a "continuing love affair with technology and professional power" (Doherty, Baird, & Becker, 1986). Rather, confronted with an ingrown toenail or a case of the common cold, I find myself unable to be "a truly enlightened doctor who resonates with the full psychosocial context of the patient's problem" (Doherty, Baird, & Becker, 1986).

We do not practice in a vacuum and we must make peace with the fact that our patients are evincing more medical sophistication than ever before. They read reports in the lay press culled from the most prestigious medical journals and, as a result, our diagnostic clay feet have become obvious to them. How often do we hear, after "exploring the context" and performing a thorough physical examination, "Doctor, don't you think I should have some test?" Balint (1973) decried the "first rule out organic disease" attitude taken even by the psychiatrists of his day and insisted that an attempt be made to understand the patient while the results of the barium swallow are awaited. Nowadays, matters are not so simple, and people are likely to resist "nonmedical" interventions until all "nuts and bolts" avenues have been exhausted. In the imaginative garden of biopsychosocial medicine, the toads are real and, unfortunately, one is still more likely to be hauled up for malpractice over a serum calcium that was not ordered than for failing to elicit that the patient has a brother in another city who is suffering from multiple sclerosis.

The split model, according to Doherty, Baird, and Becker (1986), relegates the psychosocial to the position of being just another tool in the doctor's bag--one that he will call on when needed, just as he will, under other circumstances, use his knowledge of orthopedics or dermatology. These authors state that Engel also looked upon the split model as being insufficiently coherent and a framework within which the strongest pull is back toward the comparative safety of the biomedical. However, Engel stated elsewhere that "it is the doctor's, not the patient's, responsibility to establish the nature of the problem and to decide whether ... it is best handled in a medical framework" (Engel, 1977). Furthermore "the physician's basic professional knowledge and skills must span the social, psychological and biological, for his decisions and actions on the patient's behalf involve all three." Here the key word is "span," which implies that the physician is the whole and each of the three categories is one of his parts, with no indication that they must always be employed simultaneously.

The hint at the selective application of the biopsychosocial approach contained in the two passages just quoted seems to me to vindicate the split model, which leaves the doctor sufficient autonomy to draw on the resources at his disposal according to this lights and, perhaps most of all, according to his limitations. It leaves ample room for what Drossman called a symptom-oriented technique, which reaches out to a possible psychosocial source through, rather than around, the physical complaint (Drossman, 1978). By staying with the symptom and exploring its context, the doctor conveys to the patient the belief in its reality and avoids the moment when the patient senses that he or she is about to be told: "It's all in your head."

The split model affords flexibility, allowing the doctor to provide etiologic treatment for iron-deficiency anemia or hypothyroidism without feeling that the diagnosis is incomplete. It condones the doctor's listening to the patient with "one ear attuned to the organic and the other to the psychosocial" (G. Smilkstein, personal communication) while recognizing that some people articulate the symptoms of serious underlying disease in a diffuse manner suggestive of a "problem of living" (Engel, 1988), as exemplified by the woman with gastrointestinal bleeding described earlier. The freedom of motion provided for is precisely what is needed in everyday practice, in which awareness of the larger picture should remain in the background and not obtrude on the treatment of isolated instances of banal illness.

There is no reason why the split model should not allow the doctor to practice patient-centered care (Levenstein et al., 1986) because the necessary open-ended interviewing techniques are available within its framework, too. As a family doctor who was born without the higher gift of permanent biopsychosocialibity, and, out of this weakness, having unabashedly identified myself with the split model, I find that I am no longer plagued with the feeling that I do not practice what I preach. From the safety of its confines, I can even permit myself a little Freudian revenge fantasy: I wake up one morning, open the latest issue of a medical journal with psychosocial overtones, and discover that it has just been convincingly demonstrated, ps, rs, alphas, and all, that the split model is what Engel had in mind from the beginning!

Nearly a century ago, Osler is reported to have said: "It is sometimes more important to know what patient has a disease than what disease a patient has"--a powerful statement indeed coming from a reductionist with virtually no therapeutic options. The split model has moved me from "sometimes" to "usually;" the transition to "always" lies ahead.

REFERENCES

Antonovsky, A. (1979). Health, stress and coping: New perspectives on mental and physical well-being. San Francisco: Jossey-Bass.

Balint, M. (1973). The doctor, his patient and the illness. London: Pitman Medical.

Barsky, A. J. (1979). Patients who amplify bodily sensations. Annals of Internal Medicine, 91, 63-70.

Dixon, A. S. (1983). Family medicine--At a loss for words? Journal of the Royal College of General Practitioners, 33, 358-363.

Doherty, W. J., Baird, M. A., & Becker, L. A. (1986). Family medicine and the biopsychosocial model: The road toward integration. Advances, 3, 17-28.

Drossman, D. A. (1978). The problem patient. Annals of Internal Medicine, 88, 366-372.

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.

Engel, G. L. (1988). How much longer must medicine's science be bound by a seventeenth century world view? In K. L. White (Ed.), The task of medicine. Menlo Park, CA: Henry J. Kaiser Family Foundation.

Kleinman, A., Eisenberg, L., & Good, B. Culture, illness and care: Clinical lessons from anthropologists and cross-cultural research. Annals of Internal Medicine, 197, 88, 251-258.

Levenstein, J. H., McCracken, E. C., McWhinney, I. R., et al. (1986). The patient-centred clinical method. I. A model for the doctor-patient interaction in family practice. Family Practice, 3, 24-30.

Schwartz, M. A., & Wiggins, O. P. (1988). Scientific and humanistic medicine: A theory of clinical methods. In K. L. white (Eds.), The task of medicine. Menlo Park, CA: Henry J. Kaiser Family Foundation.

Smilkstein, G. (1978). The family APGAR: A proposal for a family function test and its use by physicians. Journal of Family Practice, 6, 1231-1239.

Correspondence concerning this article should be addressed to Dr. Herman at Assia Community Health Center, Netivot, Israel.

* First published in Family Systems Medicine, Vol. 7, No. 1, 1989 [C] FSH, Inc.

Joseph Herman, MD, previously Chair of the Department of Family Medicine, Division of Health in the Community, University Center for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel, is now retired and works part time in a teaching clinic in Netivot.
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Author:Herman, Joseph
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Date:Dec 22, 2005
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