Biopsychosocial Aspects of Chronic Medical Conditions

Psychological Aspects of Chronic Illness ¡  Psychological aspects of chronic illness are

commonly overlooked ¡  Most patients adjust well to the psychological

aspects of chronic illness

¡  However, adjustment can decrease when when patients experience a decline in physical health status and when patients experience stigma as a result of:

¡  Limited independence ¡  Negative impact on daily routine ¡  Increase self-care demands ¡  Dynamic nature of life changes

Locus of Control & Psychological Vulnerabilities ¡  Patients with chronic illness have to balance their

need to be in control of their lives with the need to have significant others “take over” certain aspects of their life/care at times

¡  Psychological difficulties may complicate the management of a chronic medical condition ¡  Can make assessment and formulations complex ¡  Do psychological problems make us vulnerable to

chronic illness? Does chronic illness make us vulnerable to experiencing psychological distress that results in a psychological disorder?

Factors Impacting Chronic Illness Management ¡  Information/Knowledge

¡  A patient’s access to information influences their help-seeking behaviors and is highly related to a patient’s contact with health-service providers

¡  Psychophysiology ¡  Patients can experience deleterious effects as a result of the impact that illness-related stress

can have on their illness-related symptomatology (i.e., stress aggravates arthritic pain)

¡  Behavior Change ¡  A patient’s ability to modify their behavior can have significant consequences on the

management of their disease (e.g., quit smoking in cancer treatment or increased exercise in Type 2 Diabetes)

¡  Social Support ¡  Social support can mediate a patient’s interaction with the health care system

¡  Somatization ¡  Physical symptoms that arise as a result of undiagnosed psychological problems or emotional

distress can make a illness presentation more complex

Factors Impacting Chronic Illness Management

Illness Management

& Patient Help-Seeking

Behaviors

Information/ Knowledge

Psychophysiology

Behavior Change Social Support

Undiagnosed Psychological

Disorder

Somatization

Psychological Adjustment ¡  There is a HUGE variation in the SUBJECTIVE impact of chronic

medical conditions that are similar in severity

¡  Illness representation ¡  The subjective experience of the illness determines a patients ability

to cope and manage the chronic medical condition. This affects:

¡  A patient’s reactions to their symptoms ¡  Self-care behaviors ¡  Changes in mood states

¡  Our job as providers is to help patients find the appropriate framework for ascribing MEANING to their illness/symptoms

¡  We need to help patients understand and cope with their illness in light of pre-existing beliefs and assumptions about their world

Illness Representation Themes Identity

• Diagnostic label and the symptoms viewed as part of the chronic illness

Cause

• Personal ideas about causality

• Explanatory models (can be single or multiple causality model)

Timeline

• How long the individual expects the illness will last

Consequences

• Expected impact or effects and outcome of the illness

Cure/Control

• How the individual anticipates recovery from and control of the illness

§  These themes reflect and individual’s perceptions and beliefs about the illness. They provide patients a framework to make sense of their symptoms, assess their health status, predict treatment adherence, and help patients cope with their medical condition.

§  Assessing and modifying illness perceptions is a key component of biopsychosocial interventions

§  What factors influence a patient’s illness perception?

Stress & Illness ¡  Stress is a universal phenomenon

¡  Stress is particularly present and significant in individuals with chronic illnesses

¡  Stress has been linked to higher morbidity and mortality

¡  Stress has been identified as a significant predictor of symptomalotogy in chronic illness

¡  Stress is one of the most compelling constructs in the biopsychosocial model of illness

¡  Please watch the following video in preparation for this week’s discussion-NIH Vcast Stress and Health: From Molecules to Societies by Robert Sapolsky, Ph.D, Stanford University: ¡  http://youtu.be/XvMQQsyPirM

Conclusions ¡  As providers working with chronically ill patients

we need to have a clear understanding of:

¡  1). The role of a chronic stress response in illness-

related symptomatology and management

¡  2)A patient’s illness presentation across domains and how that impacts or could potentially impact their adherence to treatment and their ability to cope with the multiple challenges of living with a chronic medical condition

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The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientifi c Inquiry

ABSTRACT The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjec- tive experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a nec- essary contribution to the scientifi c clinical method, while suggesting 3 clarifi ca- tions: (1) the relationship between mental and physical aspects of health is com- plex—subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician- patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical prac- tice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming thera- peutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In con- clusion, the value of the biopsychosocial model has not been in the discovery of new scientifi c laws, as the term “new paradigm” would suggest, but rather in guid- ing parsimonious application of medical knowledge to the needs of each patient.

Ann Fam Med 2004;2:576-582. DOI: 10.1370/afm.245.

GEORGE ENGEL’S LEGACY

T he late George Engel believed that to understand and respond adequately to patients’ suffering—and to give them a sense of being understood—clinicians must attend simultaneously to the biologi-

cal, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated indus- trialized societies since the mid-20th century.1 His new model came to be known as the biopsychosocial model. He formulated his model at a time when science itself was evolving from an exclusively analytic, reductionis- tic, and specialized endeavor to become more contextual and cross-disci- plinary.2-4 Engel did not deny that the mainstream of biomedical research had fostered important advances in medicine, but he criticized its exces- sively narrow (biomedical) focus for leading clinicians to regard patients as objects and for ignoring the possibility that the subjective experience of the patient was amenable to scientifi c study. Engel championed his ideas not only as a scientifi c proposal, but also as a fundamental ideology that tried to reverse the dehumanization of medicine and disempowerment of patients (Table 1). His model struck a resonant chord with those sectors of the medical profession that wished to bring more empathy and compassion into medical practice.

In this article we critically examine and update 3 areas in which the biopsychosocial model was offered as a “new medical paradigm”5,6: (1) a

Francesc Borrell-Carrió, MD1

Anthony L. Suchman MD2,3

Ronald M. Epstein MD4 1Department of Medicine, University of Barcelona, CAP Cornellà, Catalonian Institute of Health (ICS), Cornellà de Llobregat, Spain

2Relationship Centered Health Care, Rochester, NY

3Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY

4Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY

CORRESPONDING AUTHOR

Francesc Borrell-Carrió, MD Department of Medicine University of Barcelona CAP Cornellà, Catalonian Institute of Health (ICS) C/Bellaterra 39 08940 Cornellà de Llobregat, Spain [email protected]

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world view that would include the patient’s subjective experience alongside objective biomedical data, (2) a model of causation that would be more comprehensive and naturalistic than simple linear reductionist models, and (3) a perspective on the patient-clinician relation- ship that would accord more power to the patient in the clinical process and transform the patient’s role from passive object of investigation to the subject and protagonist of the clinical act. We will also explore the interface between the biopsychosocial model and evi- dence-based medicine.

DUALISM, REDUCTIONISM, AND THE DETACHED OBSERVER In advancing the biopsychosocial model, Engel was responding to 3 main strands in medical thinking that he believed were responsible for dehumanizing care. First, he criticized the dualistic nature of the biomedi- cal model, with its separation of body and mind (which is popularly, but perhaps inaccurately, traced to Des- cartes).7,8 This conceptualization (further discussed in the supplemental appendix, available online at http://

www.annfammed.org/cgi/content/full/2/6/576/ DC1) included an implicit privileging of the

former as more “real” and therefore more worthy of a scientifi c clinician’s attention. Engel rejected this view for encouraging physicians to maintain a strict separation between the body-as-machine and the nar- rative biography and emotions of the person—to focus on the disease to the exclusion of the person who was suffering—without building bridges between the two realms. His research in psychosomatics pointed toward a more integrative view, showing that fear, rage, neglect, and attachment had physiologic and develop- mental effects on the whole organism.

Second, Engel criticized the excessively materialis-

tic and reductionistic orientation of medical thinking. According to these principles, anything that could not be objectively verifi ed and explained at the level of cel- lular and molecular processes was ignored or devalued. The main focus of this criticism—a cold, impersonal, technical, biomedi- cally-oriented style of clinical practice—may not have been so much a matter of underlying philosophy, but discomfort with practice that neglected the human dimension of suffering. His semi- nal 1980 article on the clinical application of the biopsychoso-

cial model5 examines the case of a man with chest pain whose arrhythmia was precipitated by a lack of caring on the part of his treating physician.

The third element was the infl uence of the observer on the observed. Engel understood that one cannot understand a system from the inside without disturbing the system in some way; in other words, in the human dimension, as in the world of particle physics, one can- not assume a stance of pure objectivity. In that way, Engel provided a rationale for including the human dimension of the physician and the patient as a legiti- mate focus for scientifi c study.

Engel’s perspective is contrasted with a so-called monistic or reductionistic view, in which all phenom- ena could be reduced to smaller parts and understood as molecular interactions. Nor did he endorse a holis- tic-energetic view, many of whose adherents espouse a biopsychosocial philosophy; these views hold that all physical phenomena are ephemeral and control- lable by the manipulation of healing energies. Rather, in embracing Systems Theory,2 Engel recognized that mental and social phenomena depended upon but could not necessarily be reduced to (ie, explained in terms of) more basic physical phenomena given our current state of knowledge. He endorsed what would now be considered a complexity view,9 in which differ- ent levels of the biopsychosocial hierarchy could inter- act, but the rules of interaction might not be directly derived from the rules of the higher and lower rungs of the biopsychosocial ladder. Rather, they would be considered emergent properties that would be highly dependent on the persons involved and the initial con- ditions with which they were presented, much as large weather patterns can depend on initial conditions and small infl uences.9 This perspective has guided decades of research seeking to elucidate the nature of these interactions.

Table 1. Engel’s Critique of Biomedicine

1. A biochemical alteration does not translate directly into an illness. The appearance of illness results from the interaction of diverse causal factors, including those at the molecular, individ- ual, and social levels. And the converse, psychological alterations may, under certain circum- stances, manifest as illnesses or forms of suffering that constitute health problems, including, at times, biochemical correlates

2. The presence of a biological derangement does not shed light on the meaning of the symp- toms to the patient, nor does it necessarily infer the attitudes and skills that the clinician must have to gather information and process it well

3. Psychosocial variables are more important determinants of susceptibility, severity, and course of illness than had been previously appreciated by those who maintain a biomedical view of illness

4. Adopting a sick role is not necessarily associated with the presence of a biological derangement

5. The success of the most biological of treatments is infl uenced by psychosocial factors, for example, the so-called placebo effect

6. The patient-clinician relationship infl uences medical outcomes, even if only because of its infl u- ence on adherence to a chosen treatment

7. Unlike inanimate subjects of scientifi c scrutiny, patients are profoundly infl uenced by the way in which they are studied, and the scientists engaged in the study are infl uenced by their subjects

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COMPLEXITY SCIENCE: CIRCULAR AND STRUCTURAL CAUSALITY

Engel objected to a linear cause-effect model to describe clinical phenomena. Clinical reality is far more complex. For example, although genetics may have a role in causing schizophrenia, no clinician would ignore the sociologic factors that might unleash or con- tain the manifestations of the illness.

Complexity and Causality Few morbid conditions could be interpreted as being of the nature “one microbe, one illness”; rather, there are usually multiple interacting causes and contributing factors. Thus, obesity leads to both diabetes and arthri- tis; both obesity and arthritis limit exercise capacity, adversely affecting blood pressure and cholesterol lev- els; and all of the above, except perhaps arthritis, con- tribute to both stroke and coronary artery disease. Some of the effects (depression after a heart attack or stroke) can then become causal (greater likelihood of a second similar event). Similar observations can be made about predictors of relapse in schizophrenia. These obser- vations set the stage for models of circular causality, which describes how a series of feedback loops sustain a specifi c pattern of behavior over time.10-13 Complex- ity science is an attempt to understand these complex recursive and emergent properties of systems14,15 and to fi nd interrelated proximal causes that might be changed with the right set of interventions (family support and medications for schizophrenia; depression screening and cholesterol level reduction after a heart attack).

Structural Causality In contrast to the circular view, structural causality describes a hierarchy of unidirectional cause-effect relationships—necessary causes, precipitants, sustaining forces, and associated events.16 For instance, a neces- sary cause for tuberculosis is a mycobacterium, precipi- tants can be a low body temperature, and a sustaining force a low caloric intake. Complexity science can facilitate understanding of a clinical situation, but most of the time a structural model is what guides practical action. For example, if we think that Mr. J is hyperten- sive because he consumes too much salt, has a stress- ful job, poor social supports, and an overresponsible personality type, following a circular causal model, possibly all of these factors are truly contributory to his high blood pressure. But, when we suggest to him that he take an antihypertensive medication, or that he con- sume less salt, or that he take a stress-reduction course, or that he see a psychotherapist to reduce his sense of guilt, we are creating an implicit hierarchy of causes: Which cause has the greatest likely contribution to his

high blood pressure? Which would be most responsive to our actions? What is the added value of this action, after having done others? Which strategy will give the greatest result with the least harm and with the least expenditure of resources?

Interpretations, Language, and Causality Causal attributions have the power to create reality and transform the patient’s view of his/her own world.17 A physician who listens well might agree when a patient worries that a family argument precipitated a myo- cardial infarction; although this interpretation may have meaning to the patient, it is inadequate as a total explanation of why the patient suffered a myocardial infarction. The attribution of causality can be used to blame the patient for his or her illness (“If only he had not smoked so much.…”), and also may have the power of suggestion and might actually worsen the patient’s condition (“Every time there is a fi ght, your dizziness worsens, don’t you see?”).

TOWARD A RELATIONSHIP-CENTERED MODEL Power and Emotions in the Clinical Relationship Patient-centered, relationship-centered, and client-cen- tered approaches18-24 propose that arriving at a correct biomedical diagnosis is only part of the clinician’s task; they also insist on interpreting illness and health from an intersubjective perspective by giving the patient space to articulate his or her concerns, fi nding out about the patient’s expectations, and exhorting the health professional to show the patient a human face. These approaches represent movement toward an egali- tarian relationship in which the clinician is aware of and careful with his or her use of power.

This “dialogic” model suggests that the reality of each person is not just interpreted by the physician, but actually created and recreated through dialogue25-31; individual identities are constructed in and maintained through social interaction.32 The physician’s task is to come to some shared understanding of the patient’s narrative with the patient. Such understanding does not imply uncritical acceptance of whatever the patient believes or hypothesizes, but neither does it allow for the uncritical negation of the patient’s perspective, as so frequently occurs, for example, when patients com- plain of symptoms that physicians cannot explain.33,34 The patient’s story is simultaneously a statement about the patient’s life, the here-and-now enactment of his life trajectory, and data upon which to formulate a diagnosis and treatment plan.

Underlying the analysis of power in the clinical relationship is the issue of how the clinician handles the

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strong emotions that characterize everyday practice. On the one hand, there is a reactive clinical style, in which the clinician reacts swiftly to expressions of hostility or distrust with denial or suppression. In contrast, a proac- tive clinical style, characterized by a mindful openness to experience, might lead the clinician to accept the patient’s expressions with aplomb, using the negative feelings to strengthen the patient-clinician relationship.35 The clini- cian must acknowledge and then transcend the tendency to label patients as “those with whom I get along well” or “diffi cult patients.” By removing this set of judgments, true empathy can devolve from a sense of solidarity with the patient and respect for his or her humanity, leading to tolerance and understanding.18 Thus, in addition to the moral imperative to treat the patient as a person, there is a corresponding imperative for the physician to care for and deepen knowledge of himself or herself.35,36 Without a suffi cient degree of self-understanding, it is easy for the physician to confuse empathy with the projection of his or her needs onto the patient.

Implications for Autonomy Most patients desire more information from their physicians, fewer desire direct participation in clinical decisions, and very few want to make important deci- sions without the physician’s advice and consultation with their family members.37-40 This does not mean that patients wish to be passive, even the seriously ill and the elderly.41 In some cases, however, clinicians unwittingly impose autonomy on patients.19,42,43 Making a reluctant patient assume too much of the burden of knowledge about an illness and decision making, without the advice from the physician and support from his or her family, can leave the patient feeling abandoned and deprived of the physician’s judgment and expertise.42 The ideal, then, might be “autonomy in relation”—an informed choice supported by a caring relationship.19 The clini- cian can offer the patient the option of autonomy41

while considering the possibility that the patient might not want to know the whole truth and wish to exercise the right to delegate decisions to family members.40,44

The Social Milieu There is an ecological dimension of each encounter—it is not just between patient and physician, but rather an expression of social norms.45 Sometimes clinicians face a dilemma: can or should a private clinical relationship between patient and physician be a vehicle for social transformation? Or, should the relationship honor and conform to the cultural norms of patients?19 Our view is that adaptation normally should occur before transfor- mation—the physician must fi rst understand and accom- modate to the patient’s values and cultural norms before trying to effect change. Otherwise, the relationship

becomes a political battleground and the focus of a pro- cess to which the patient has not consented and may not desire. This debate, however, becomes much more diffi - cult in situations in which patients have suffered abuse— for example domestic violence or victims of torture.46

In those cases, not trying to remedy the social injustices that resulted in the patient seeking care may interfere with the formation of a trusting relationship. The physi- cian may be tempted to effect a social transformation in these cases, for example, to advise the patient to leave an abusive situation, even though the patient may state that she only wants care for the bruises. Premature advice may interfere with enabling the patient to be the agent of change, however. Stopping short of attempting to transform social relationships until the patient has given consent should not be interpreted as indifference to, acceptance of, or complicity in such situations; rather, it should be viewed as a prudent course of action that will ultimately be validating and empowering.

Caring, Paternalism, and Empathy Taking Engel’s view, perhaps it is not paternalism that is the problem but practicing as a cold technician rather than a caring healer.47,48 The physician who sees his or her role as nothing more than a technical adviser can regard empathy as a useless effort that has no infl uence on clinical decisions, or, worse, a set of linguistic tricks to get the patient to comply with treatment. Because it is entirely possible to advocate for shared decision making without challenging the notion of the cold technician, we propose to move the emphasis to an approach that emphasizes human warmth, understand- ing, generosity, and caring.

THE BIOPSYCHOSOCIAL MODEL AND RELATIONSHIP-CENTERED CARE The practical application of the biopsychosocial model, which we will call biopsychosocially oriented clinical prac- tice does not necessarily evolve from the constructs of interactional dualism or circular causality. Rather, it may be that the content and emotions that constitute the clinician’s relationship with the patient are the funda- mental principles of biopsychosocial-oriented clinical practice, which then inform the manner in which the physician exercises his or her power. The models of relationship that have tended to appear in the medical literature, with a few notable exceptions,19 have perhaps focused too much on an analysis of power and too little on the underlying emotional climate of the clinical relationship. For this reason, we suggest a reformulation of some of the basic principles of the biopsychosocial model according to the emotional tone that engraves the relationship with such characteristics as caring, trustwor-

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thiness, and openness.49,50 Some principles of biopsycho- social-oriented clinical practice are outlined below.

Calibrating the Physician The biopsychosocial model calls for expanding the number and types of habits to be consciously learned and objectively monitored to maintain the centrality of the patient.51 The physician is in some ways like a musi- cal instrument that needs to be calibrated, tuned, and adjusted to perform adequately.36 The physician’s skills should be judged on their ability to produce greater health or to relieve the patient’s suffering—whether they include creating an adequate emotional tone, gather- ing an accurate history, or distinguishing between what the patient needs and what the patient says he or she wants. In that regard, a clinical skill includes the ethical mandate not only to fi nd out what concerns the patient, but to bring the physician’s agenda to the table and infl u- ence the patient’s behavior. Sometimes doing so may include uncovering psychosocial correlates of otherwise unexplained somatic symptoms (such as ongoing abuse or alcoholism) to break the cycle of medicalization and iatrogenesis.33 To abandon this obligation, in our view, is breaking an implicit social contract between physicians and society. This deliberative and sometimes frankly physician-centered approach has its perils, however. The physician must be capable of an ongoing self-audit simply because his or her performance is never the same from moment to moment. Weick and Sutcliffe52 regard this constant vigilance as a fundamental requirement for professions that require high reliability in the face of unexpected events. Mindfulness—the habits of attentive observation, critical curiosity, informed fl exibility, and presence—underlies the physician’s ability to self-moni- tor, be vigilant, and respond with compassion.35,53,54

Creating Trust The expert clinician considers explicitly, as a core skill, the achievement in the encounter of an emotional tone conducive to a therapeutic relationship. For that reason, all consultations might be judged on the basis of cordial- ity, optimism, genuineness, and good humor. By receiv- ing a hostile patient with respect,55 it clarifi es for the cli- nician that the patient’s emotions are the patient’s—and not the physician’s—and also sets the stage for the patient to refl ect as well. Similarly, the physician must know how to recognize and when to express his or her own emotions, sometimes setting limits and boundaries in the interest of preserving a functional relationship.

Cultivating Curiosity The next step in the application of clinical evidence to medical care is the cultivation of curiosity. Thus, cultivated naïvete56 might be considered one of the

fundamental habits characteristic of expert practitioners. Another aspect of this emotional tone is an empathic curiosity about the patient as person. Empathic curiosity allows the clinician to maintain an open mind and not to consider that any case is ever closed. If the patient does not surprise us today, perhaps he or she will tomorrow. We have described this capacity using the term, beginner’s mind.35,57 It is the capacity for expecting the unexpected, just as if the physician were another cli- nician seeing the patient for the fi rst time. There is also an ethical component of this emotional tone—there are no “good” or “bad” patients, nor are there “interesting” and “boring” diseases. Patients should not have to legiti- mize their suffering by describing illnesses that make the clinician feel comfortable or confi dent.58

Recognizing Bias The grounding of medical decisions based on scientifi c evidence while also integrating the clinician’s professional experience is now a well-accepted tenet of the founders of the evidence-based medicine movement.59 The method for incorporation of experience, however, has been less well described than the method for judging the quality of scientifi c evidence. For example, clinicians should learn how their decisions might be biased by the race and sex of the patient, among other factors,51 and also the ten- dency to close the case prematurely to rid oneself of the burden of attempting to solve complex problems.60

Educating the Emotions There are methods for emotional education, just as there are for learning new knowledge and skills.35

Tolerance of uncertainty, for example, is amenable to observation and calibration—making decisions in the absence of complete information is a characteristic of an expert practitioner, in contrast to the technician who views his role as simply following protocols.

Using Informed Intuition The role of intuition is central. Just as Polanyi and Schön maintain that professional competence is based in tacit, rather than explicit, knowledge,61,62 expertise often is manifest in insights that are diffi cult to track on a strictly cognitive level. If a clinician, encountering a situation in which he normally would use a particu- lar treatment, has the intuition, for a reason that has not yet become clear, that treatment might not be the best for this particular patient, we suggest, rather than considering it a feeling from nowhere that might be dis- carded, perhaps the intuition can later be traced to a set of concrete observations about the patient that were not easy for the clinician to describe at the time. Because these observations often are manifest only when cases are reviewed after the fact does not diminish the ethical

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obligation that the clinician use all of his or her capa- bilities, not only those which can be readily explained.

Communicating Clinical Evidence Evidence should be communicated in terms the patient can understand, in small digestible pieces, at a rate at which it can be assimilated. Information overload may have two effects—reduction in comprehension and increasing the emotional distance between physi- cian and patient. Communication of clinical evidence should foster understanding, not simply answers.63

FURTHER DEVELOPMENT OF THE BIOPSYCHOSOCIAL MODEL George Engel formulated the biopsychosocial model as a dynamic, interactional, but dualistic view of human experience in which there is mutual infl uence of mind and body. We add to that model the need to balance a circular model of causality with the need to make linear approximations (especially in planning treatments) and the need to change the clinician’s stance from objective detachment to refl ective participation, thus infusing care with greater warmth and caring. The biopsycho- social model was not so much a paradigm shift—in the sense of a crisis of the scientifi c method in medicine or the elaboration of new scientifi c laws—as it was an expanded (but nonetheless parsimonious) application of existing knowledge to the needs of each patient.

In the 25 years that have elapsed since Engel fi rst proposed the biopsychosocial model, two new intellec- tual trends have emerged that could make it even more robust. First, we can move beyond the problematic issue of mind-body duality by recognizing that knowl- edge is socially constructed. To some extent, such categories as “mind” or “body” are of our own creation. They are useful to the extent that they focus our think- ing and action in helpful ways (eg, they contribute to health, well-being, and effi cient use of resources), but when taken too literally, they can also entrap and limit us by creating boundaries that need not exist. By main- taining what William James called “fragile” categories,64 we can alter or dispose of categories as new evidence accumulates and when there is a need to engage in fl ex- ible, out-of-the-box thinking.

Second, we can move beyond the multidimensional and multifactorial linear thinking to consider complex- ity theory as a more adequate model for understanding causality, dualism, and participation in care. Complex- ity theory shows how, in open systems, it is often impossible to know all of the contributors to and infl u- ences on particular health outcomes. By describing the ways in which systems tend to self-organize, it provides guideposts to inform the clinician’s actions. It also buf-

fers the tendency to impose unrealistic expectations that one can know and control all of these contributors and infl uences.65

George Engel’s most enduring contribution was to broaden the scope of the clinician’s gaze. His bio- psychosocial model was a call to change our way of understanding the patient and to expand the domain of medical knowledge to address the needs of each patient. It is perhaps the transformation of the way illness, suffering, and healing are viewed that may be Engel’s most durable contribution.

To read or post commentaries in response to this article, see it online at http://www.annfammed.org/cgi/content/full/2/6/576.

Key words: Biopsychosocial model; clinical practice patterns; personal autonomy; empathy; communication; education

Submitted September 25, 2003; submitted, revised, January 28, 2004; accepted February 10, 2004.

Acknowledgments: The following people have provided important cri- tiques of this article. We thankfully acknowledge their contributions, but do not infer that they take responsibility for the content of the article: Drs. Rogelio Altisent, Lucy M. Candib, Jordi Cebrià, José Corrales, Blas Coscollar, Javier García-Campayo, Salvador García-Sánchez, Diego Gracia, Maria León, Susan McDaniel, Fernando Orozco, Vicente Ortún, Timothy Quill, Roger Ruiz, Jorge Tizón, and Lyman Wynne.

References 1. Engel G. The need for a new medical model: a challenge for bio-

medicine. Science. 1977;196:129-136.

2. von Bertanlaffy L. Perspectives on General System Theory. New York, NY: George Braziller, Inc; 1975.

3. Kiel LD, Elliot E. Chaos Theory in the Social Sciences. Ann Arbor, Mich: University of Michigan Press; 1996.

4. Minuchin S, Rosman BL, Baker L. Psychosomatic Families. Cambridge: Harvard University Press; 1978.

5. Engel G. The clinical appplication of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544.

6. Engel GL. How much longer must medicine’s science be bounded by a seventeenth century world view? In: White KL, ed. The Task of Medicine: Dialogue at Wickenburg. Menlo Park, Calif: The Henry Kaiser Family Foundation; 1988:113-136.

7. Brown TM. Cartesian dualism and psychosomatics. Psychosomatics. 1989;30:322-331.

8. Damasio AR. Descartes’ Error. New York, NY: Putnam’s Sons; 1994.

9. Plsek P. Appendix B: Redesigning health care with insights from the science of complex adaptive systems. In: Institute of Medicine. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: National Academies Press; 2001:322-335.

10. Mackie JL. Causes and conditions. Amer Philosoph Q. 1965;2:245-264.

11. Mackie JL. The Cement of the Universe. A Study of Causation. Oxford UK: Oxford University Press; 1974.

12. Bateson G. Steps to an Ecology of Mind: A Revolutionary Approach to Man’s Understanding of Himself. New York, NY: Ballantine Books; 1972.

13. Simon FB, Stierlin H, Wynne LC. Circularity/recursiveness/circular causality. The language of family therapy. In: A Systemic Vocabulary and Sourcebook. New York, NY: Family Process Press; 1985:37-39.

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 2 , N O. 6 ✦ N OV E M B E R / D E C E M B E R 2 0 0 4

582

B I O P SY C H O S O C I A L M O D E L 2 5 Y E A RS L AT E R

14. Fraser SW, Greenhalgh T. Coping with complexity: educating for capability. BMJ. 2001; 323:799-803.

15. Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory [see com- ments]. J Fam Pract. 1998; 46:369-376.

16. Sackett DL, Haynes RB, Tugwell P, Guyatt GH. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, Mass: Little Brown and Co; 1992.

17. Kirmayer LJ. Mind and body as metaphors: hidden values in bio- medicine. In: Lock M, Gordon DR, eds. Biomedicine Examined. Boston, Mass: Kluwer Academic Publishers; 1988:57-93.

18. Entralgo PL. Doctor and Patient. New York, NY: McGraw-Hill Book Company; 1969.

19. Candib LM. Medicine and the Family: A Feminist Perspective. New York, NY: Basic Books; 1995.

20. Tresolini C, Pew-Fetzer Task Force. Health Professions Education and Relationship-Centered Care. San Francisco, Calif: Pew Health Professions Commission; 1994.

21. Mead N, Bower P. Measuring patient-centredness: a comparison of three observation-based instruments. Patient Educ Couns. 2000;39:71-80.

22. Putnam SS, Lipkin M. The patient-centered interview: research sup- port. In: Lipkin M, Putnam SM, Lazare A. The Medical Interview. New York, NY: Springer-Verlag; 1995.

23. Stewart M. Towards a global defi nition of patient centered care. BMJ. 2001; 322:444-445.

24. Tizón J. Psychological Components of Medical Practice. Barcelona: Doyma;1989.

25. Bartz R. Beyond the biopsychosocial model. New approaches to doc- tor-patient interactions. J Fam Pract. 1999;48:601-607

26. Habermas J. The Theory of Communicative Action: Volume I. Reason and the Rationalization of Society. Boston, Mass: Beacon; 1984.

27. Frank AW. The Wounded Storyteller. Chicago, Ill: The University of Chicago Press; 1995.

28. Borkan JM, Quirk M, Sullivan M. Finding meaning after the fall: injury narratives from elderly hip fracture patients. Soc Sci Med. 1991;33:947-957.

29. Hunter KM. Doctors’ Stories: The Narrative Structure of Medical Knowl- edge. Princeton, NJ: Princeton University Press; 1991.

30. Jones AH. Narrative based medicine: narrative in medical ethics. BMJ. 1999; 1999;318:253-256.

31. Kleinman AM. The Illness Narratives: Suffering, Healing, and the Human Condition. New York, NY: Basic Books; 1988.

32. Mead GH. Mind, Self and Society. Chicago, Ill: The University of Chi- cago Press; 1962.

33. Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: incorporating the patient’s experience of illness. Arch Int Med. 1999;159:215-222.

34. Salmon P, Peters S, Stanley I. Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999;318:372-376.

35. Epstein RM. Mindful practice. JAMA. 1999;282:833-839.

36. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502-509.

37. Torío J, García MC. The clinical interview and the patient-physician relationship: opinions and preferences of consumers. Aten Primaria. 1997;19:44-60.

38. Torío J, García MC. The clinical interview and the patient-physician relationship: opinions and preferences of consumers. Aten Primaria. 1997;19:63-74.

39. Torio J, García MC. Evaluation of patient-orientation in primary care practice. Aten Primaria. 1997;20:45-55.

40. Candib L. Truth telling and advance planning at the end of life: problems with autonomy in a multicultural world. Fam Syst Health. 2002;20:213-228.

41. Slivinske LR, Fitch VL. The effect of control enhancing interventions on the well-being of elderly individuals living in retirement commu- nities. Gerontologist. 1987; 27:176-181.

42. Quill TE, Brody H. Physician recommendations and patient autono- my: fi nding a balance between physician power and patient choice. Ann Intern Med. 1996;125:763-769.

43. Broggi MA. The relationship of solidarity in the clinic. A Mediterranean alternative. Homage to Lain Entralgo. JANO. 2000;1329:103-104.

44. Borrell-Carrió F, Prados JA. Bad News. Simple Strategies for Complex Situations. Barcelona: Doyma; 1995.

45. Tizón J. Componentes Psicológicos de la Práctica Médica: Una Perspec- tiva Desde la Atención Primaria [Psychological Components of Medical Practice]. Doyma: Barcelona; 1989.

46. Candib L. Working with suffering. Patient Educ Couns. 2002;48:43-50.

47. Emanuel EJ, Emanuel LL. Four models of the physician-patient rela- tionship. JAMA. 1992;267:2221-2226.

48. Ubel PA. “What should I do, doc?”: Some psychologic benefi ts of physician recommendations. Arch Intern Med. 2002;162:977-980.

49. Epstein RM, Morse DS, Williams GC, et al. Clinical practice and the biopsychosocial model. In: Quill TE, Frankel RM, McDaniel SH, eds. The Biopsychosocial Model. New York, NY: University of Rochester; 2002.

50. Borrell-Carrió F, Cebrià J. The helping relationship and the biopsy- chosocial model. In: Martín Zurro A, Cano F, eds. Atención Primaria. Madrid: Harcourt Brace; 1995.

51. Epstein RM, Mindful practice in action (II): cultivating habits of mind. Fam Syst Health. 2003;21:11-17.

52. Weick KM, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, Calif: Jossey-Bass; 2001.

52. Novack DH, Epstein RM, Paulsen RH. Toward creating physician- healers: fostering medical students’ self-awareness, personal growth, and well-being. Acad Med. 1999;74:516-520.

53. Epstein RM. Mindful practice in action I: technical competence, evidence-based medicine and relationship-centered care. Fam Syst Health. 2003;21:1-10.

55. Santorelli, S. Heal Thy Self. Lessons on Mindfulness in Medicine. New York, NY: Bell Tower; 1999.

56. Dewey J. Experience and Nature. New York, NY: Dover; 1958.

57. Suzuki S. Zen Mind, Beginner’s Mind. New York, NY: Weatherhill; 1980.

58. Dowrick C, May C, Bundred P. The biopsychosocial model of general practice: rhetoric or reality? Br J Gen Pract. 1996;46:105-107.

59. Haynes RB. BMC Health Services Research 2002. Available at http:// www.biomedcentral.com/1472-6963/2/3.

60. Borrell-Carrió F, Epstein RM. Preventing clinical errors: a call for self- awareness. Ann Fam Med. 2004:2:310-316.

61. Polanyi M. Personal Knowledge: Towards a Post-Critical Philosophy. Chi- cago, Ill: University of Chicago Press; 1974.

62. Schon DA. Educating the Refl ective Practitioner. San Francisco, Calif: Jossey-Bass; 1987.

63. Epstein RM, Quill TE, Alper B. Communicating evidence for informed decision-making. JAMA. 2004;291:2359-2366.

64. James W. Pragmatism: A New Name for Some Old Ways of Thinking. New York, NY: Longmans Green; 1907.

65. Stacey RD. Complex Responsive Processes in Organizations: Learning and Knowledge Creation. London: Routledge; 2001.

ì   Biopsychosocial  View  of  Chronic  Illness   Incorpora)ng  Psychological,  Social,  &  Cultural  Factors  in  Chronic  Illness  Management    

ì   The  Biopsychosocial  Model  

Incorpora)ng  Psychological,  Social,  &  Cultural  Factors  in  Chronic  Illness  Management  

• Preven)on   • Help-­‐Seeking   • Illness   Management  

• Self-­‐efficacy  

• Stressors   • Cause,  experience,  &   expression  of  chronic   illness  

• Rela)onships   • Spirituality   • Cultural  Expecta)ons  

• Personality/Iden)ty   • Psychological  Func)oning   • Appraisal   • Coping   • Self-­‐conscious   • Processing   • Communica)on  

• Systems  Func)on:   • Peripheral  Organ   • Immune     • Neuroendocrine     • Central  Nervous  

• Automa)c   • Outside  Consciousness  &   Awareness  

Biology   Psychology  

Behavioral   Protec)ve   &  Risk   Factors    

Social/ Cultural  

Chronic  Illness  Defined    

ì  Chronic  illnesses  are  among  the  most  prevalent,  costly,  and   preventable  health  problems  

ì  Poses  incredible  treatment  challenges  

ì  Chronic  Illness:  The  subjec)ve  experience  of  a  chronic  medical   condi)on  which  does  not  usually  have  a  single  cause,  specific   onset,  stability  in  its  presenta)on  (i.e.,  there  is  waxing  and   waning  of  the  symptom  presenta)on),  and/or  iden)fiable  cure   leading  to  the  definite  end  of  the  disease  process.    

Onset    Abrupt  vs.  Gradual  

Dura+on    Limited  vs.  Indefinite  

Cause    Usually  Single  vs.  Mul)ple  &  Dynamic  

Diagnosis  &  Prognosis    Usually  Accurate  vs.  OXen  Uncertain  

Technological  Interven+ons    Usually  Effec)ve  vs.  OXen  Indicise/Side  Effects  Common  

Outcome    Curable  vs.  No  Cure/High  Risk  of  Remission  

Uncertainty    Minimal  vs.  Pervasive  

Knowledge    Knowledgeable  Professionals  vs.  Pa)ent  &  Professional  complementary  knowledge  

Differences  between  Acute  &  Chronic  Illness    

The  Chronic  Illness  Experience    

• Disease  onset   • Diagnosis   &Treatment  

Crisis  

• Symptom   plateau   • Illness   familiarity   • A[empt  at   pre-­‐illness   func)oning  

Stabiliza)on  

• Acceptance   • Development   of  new   iden)ty  in  the   context  of  the   illness    

Resolu)on  

Experience   the  illness   as  one  life   aspect  

Integra)on  

Not  every  individual  manages  to  journey  through  the  four  stages.  The  most  frequent  recurrent  loop  occurs  between  phase  1  and  2,  where   each  new  crisis  produces  de-­‐stabiliza)on  of  the  individual’s  biopsychosocial  system  followed  by  a  period  of  brief  stabiliza)on.  

Clinical  Considerations  in  Chronic  Illness   Management      

ì  Healing  &  Curing   ì  Curing  is  the  eradica)on  of  the  disease  while  healing  is  the  experience  of  improvement  in  

health  status  despite  the  presence  of  a  disease  process   ì  Chronic  illnesses  are  not  commonly  cured;  acknowledging  that  healing  without  curing  is  a  

reality  can  help  pa)ents  cope  and  have  an  improved  quality  of  life  

ì  Health  &  Wellness   ì  Wellness  in  the  experience  of  func)oning  at  level  where  an  individual’s  poten)al  is  

maximized  (capable);  wellness  can  coexist  with  chronic  illness  

ì  Pain,  Suffering,  &  S)gma   ì  Suffering  goes  beyond  the  conscious  experience  of  pain  (physical,  emo)onal,  or  spiritual  discomfort)  to  

include  the  knowledge  of  and  actude  towards  the  influence  of  pain  on  one’s  life.  Such  actudes  can  be   ones  of  acceptance,  indifference,  or  rejec)on  of  the  pain/discomfort.    

PROVIDERS  NEED  TO  ADDRESS    SUFFERING  AS  THE  ATTITUDINAL  DIMENSION  OF  THE  PAIN   EXPERIENCE    WHEN  IMPLEMENTING  EVIDENCE-­‐BASED  TREATMENT  PROTOCOLS.    

The  Biopsychosocial  Model  as  a  Lens  for   Chronic  Illness  Perception  

ì  The  Biopsychosocial  model  is  an  extension  of  the  biomedical   and  psychosocial  models   ì  It  allows  us  to  conceptualize  the  rela)onship  between  

biological,  psychological,  social,  and  cultural  factors  in  chronic   illness  

ì  It  is  a  comprehensive  and  systemic  perspec)ve  for   understanding  the  pa)ent  and  their  rela)onship  to  the  inner   and  outer  systems  that  impact  health  and  illness    

ì  The  interface  of  these  factors  is  COMPLEX,  with  dynamic  and   reciprocal  associa)ons  

Cultural  Factors  that  Influence     Chronic  Illness  Perception  

FACTOR   DESCRIPTION  

Intolerance  of  Suffering   Suffering  is  perceived  as  having  no  value.  The  expression  of  grief  and  sorrow  is   frowned  upon;  gender  biases  in  expression  of  suffering  (i.e.,  men  don’t  cry).  

Intolerance  of  Ambiguity   There  is  fear  of  the  unknown.  Irra)onal  fears  (e.g.,  chronic  illness  is   contagious)  lead  to  placement  of  guilt/responsibility  on  the  chronically  ill.  

Intolerance  of  Chronic   Illness  

Percep)on  than  the  non-­‐treatability  of  chronic  illness  represents  a  failure  of   modern  medicine  (unlike  acute  diseases  which  are  iden)fiable  and  treatable).  

Cultural  Fear  of  Disease   Fear  of  new/unknown  diseases  leads  to  some  diseases  being  “unacceptable”.   Pa)ents  with  “acceptable”  diseases  are  s)ll  viewed  as  “outsiders”.  

Disease  Encultura)on   The  definable  process  by  which  a  new  disease  en)ty    is  recognized.  It  begins   with  fear,  followed  by  disease  iden)fica)on  (naming),  treatment  op)ons   research,  treatment,  and  acceptance.    Process  may  take  several  years,   detrimentally  affec)ng  pa)ents  with  the  disease  in  the  early  stages  due  to   s)gma  and  discrimina)on.      

Media  Influence   Media  can  influence  and  reinforce  social  stereotypes  and  cultural  biases.   Certain  aspects  of  the  disease  may  be  overrepresented  or  drama)zed,   affec)ng  society’s  percep)on  of  the  disease  process.    

Adapted  from:  Fennell,  P.  (2003).  Managing  chronic  illness  using  the  four-­‐phase  treatment  approach.  Hoboken,  NJ:  Wiley.    

Concluding  Thoughts  

ì  The  treatment  of  pa)ents  with  chronic  illness  requires  a   comprehensive  biopsychosocial  perspec)ve  under  which  an   individual’s  biological,  psychological,  social,  cultural,  and   behavioral  protec)ve  and  risk  factors  shed  light  on  the   conceptualiza)on  and  treatment  of  their  medical  condi)on.  

ì  Acute  and  chronic  illnesses  affect  pa)ents  in  fundamentally   different  ways.  Psychosocial  responses  to  chronic  illness   correlate  highly  with  disease  severity  and  quality  of  life.  For  this   reason,  the  use  of  a  comprehensive  treatment  approach  is   impera)ve  if  providers  are  to  understand  and  facilitate  coping   processes  in  chronically  ill  pa)ents.