Introduction by Terence T. Gorski
The biopsychosocial model has been an integral part of The Gorski-CENAPS Model of recovery and relapse prevention since the late 1970’s. The recognition of this approach has proven effective and is expanding to many areas of medicine. The following article gives some interesting information.
Terence T. Gorski
Interviewing and Provider-patient Relationships are Becoming Key Issues for Primary Care
ROBERT C SMITH, MD, ScM1
1. George Engel proposed in 1961 that the biopsychosocial Model (BPSM) should become a landmark for understanding medicine as a science.1,2*
2. The BPSM prompted a revolution in medical thinking by providing a compelling rational and frame if reference for integrating the physical, psychological, social and spiritual aspects of human beings.
3. Following the revolution in physics at the turn of the last century, science gradually moved away from previous linear, cause–effect thinking.
4. To that point, understandably, medicine’s guiding biomedical model focused only on diseases.
5. Beginning with Engel’s (BPSM) model, medical thinking slowly evolved by incorporating and integrating psychosocial components into the practice of medicine.
6. The biopsychosocial model stems from what many consider the modern articulation of science, general system theory.3–5
7. Engel’s model prescribes a fundamentally different path from the still-guiding biomedical model: to be scientific, according to Engel a model for medicine must include:
(1) The biological dimensions of both health and disease of all body systems;
(2) The psychological dimensions (thinking, feeling, imagining, and higher levels is self awareness and altered consciousness);
(3) The social dimensions (interpersonal, emotional, family, and larger communit)y.
8. By integrating these multiple, interacting components of the patient as an integrated whole, the subject of medical science changes from specific organs and body system to the entire human being.
9. By seriously considering all physical and nonphysical aspects of all people studied by science we become more humanistic. We link science and humanism — critical thinking with emotionality.
10. While this revolution/evolution in medicine has not yet replaced the biomedical model, the biopsychosocial model now is taught in most medical schools, and most practitioners are familiar with the term and its meaning.6
11. The problem we now face is that the model itself does not address the intricate process needed for achieving relevant biopsychosocial understanding of the patient.
12. Identified by the Western Ontario group, “patient-centered” medicine developed as the approach (process) for implementing or operationalizing the biopsychosocial model.7–10
13. This new approach puts the patient’s needs foremost (e.g., interests, concerns, questions, ideas, requests) but continues to include disease issues.
14. When applied to clinical interviewing, we always integrate the patient-centered process with ‘doctor-centered’ interviewing for disease details.
15. By enhancing communication and provider-patient relationships (PPRs), patient-centered interviewing produces the relevant biopsychosocial reality of each patient at each visit.
16. It changes the model from an intellectual construct to a practical means for a more scientific understanding of every patient.
17. Patient-centered interviewing is the flip side of the biopsychosocial coin; they go hand-in-hand, process and content.
18. Encompassing the dyadic patient-centered approach, newly described “relationship-centered” care (RCC) goes one step further.11,12
19. RCC extends the person-centered process to the remainder of the medical system, encouraging communication and relational principles at all levels, e.g., among administrators, nurses, doctors, and unions.13
20. The Journal of General Internal Medicine highlights the PPR and communication (and, therefore, the biopsychosocial model) in primary care research.
21. For example, the work of Forrest et al. concerns the better understanding of some determinants of the PPR.14
22. They found that HMO patients rated the PPR lower when required to select a physician from a list and/or to get authorization for referral.
23. The authors avoided the common pitfall of criticizing managed care and urging a change in its rules. Rather, while the HMO is doing its job to control continuously escalating costs,15 the authors acknowledge that the focus could profitably be upon the PPR itself (and, inextricably related, communication).
24. This laudable position recognizes that the exigencies of managed care have increased already strong demands upon physicians to establish effective relationships and communication.
25. The wisdom of focusing upon the PPR and not recommending simple administrative change can be found in a literature replete with the health outcome benefits of being patient-centered, many of which studies were randomized controlled trials; see reviews.16–18
26. The authors caution rightly that study other than their cross-sectional work will be needed to place their findings in proper perspective. For example, we do not know if administrative changes will have any impact on health without simultaneously addressing communication/PPR.
27. Heisler et al. did not directly study the PPR but evaluated closely related communication-based predictors:
– patients’ perceptions of participatory decision making,
– informing patients, and understanding.19
29. They found that self-reported, improved outcomes of diabetes self-management were closely related to informing patients and, not surprisingly, to patient understanding.
29. Informing and motivating patients are key patient-centered interviewing skills.
30. But understanding alone is not sufficient, particularly where the patient may need to make unwanted changes, such as to begin a diet or quit smoking.
31. For example, the following additional factors, among others, can also affect outcomes: specific PPR variables (e.g., empathy, open-ended inquiry), self-efficacy, satisfaction, compliance, cognitive ability, stress level, autonomy, and readiness to change.
32. While the authors’ caveats about a cross-sectional study are germane, we applaud their addition to the increasing body of research indicating that patients benefit from being informed.
33. We may think we provide sufficient information, but patients typically disagree 20–22 and, perhaps with the stress of their illnesses, they often forget information they do receive.23
34. These papers, and several others in this issue, underscore the central role of communication and PPR in primary care and, therefore, the need to train students and physicians in patient-centered interviewing methods.
35. While it is encouraging that more training now occurs, we need much more teaching for both students6 and residents.24
36. Although we have effective patient-centered interviewing methods, the need to teach them remains, especially for those beyond residency training, who often have had little previous exposure.
37. For continuing medical education and faculty development, a wonderful resource has evolved (nurtured by the Society of General Internal Medicine) over the last 2 decades and has been a unique, valuable dissemination mechanism: The American Academy on Physician and Patient (AAPP) (www.physicianpatient.org ). AAPP provides week-long training at its annual meeting (June) and also frequently conducts 1- to 2-day training sessions throughout the United States, always tailored to the needs and interests of those who invite them.
38. The amount as well as the quality of research about PPR/communication can encourage us. These works provide testimony to our increasing focus upon the psychosocial aspects of primary care and to moving beyond an isolated interest in disease.
39. Continuing to painstakingly generate sound evidence for “psychosocial medicine” fosters a needed maturation of this newer aspect of medicine—a prerequisite for the blossoming of a more scientific medicine.
*Of historical note, in a letter to the editor in 1961, Engel first used the term “bio-psycho-social-cultural.”25
For simplicity, the name was shortened. Engel viewed the social domain of the model as encompassing cultural, spiritual, and other broader issues (personal communication).
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