The biopsychosocial model is a vision and an approach to practice, authors say. They suggest habits of mind may be the missing link between biopsychosocial intent and clinical reality. Commitment to an ongoing process of "becoming biopsychosocial" is more pragmatic and realistic.
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The biopsychosocial model is a vision and an approach to practice, authors say. They suggest habits of mind may be the missing link between biopsychosocial intent and clinical reality. Commitment to an ongoing process of "becoming biopsychosocial" is more pragmatic and realistic.
The biopsychosocial model is a vision and an approach to practice, authors say. They suggest habits of mind may be the missing link between biopsychosocial intent and clinical reality. Commitment to an ongoing process of "becoming biopsychosocial" is more pragmatic and realistic.
RONALD M. EPSTEIN, MD FRANCESC BORRELL-CARRIO, MD In our view, the biopsychosocial model is a vision and an approach to practice rather than an empirically veriable theory, a co- herent philosophy, or a clinical method. In some cases, when that vision is confused with ideologic dogmatism, it can invite abandonment of the vision entirely or in selected situations. The authors suggest that habits of mind may be the missing link between a biopsychosocial intent and clini- cal reality. These habits of mind include attentiveness, peripheral vision, curiosity, and informed exibility. These qualities are teachable and can be reinforced. Rather than aspiring to being biopsychosocial some imagined, static statecommitment to an ongoing process of becoming biopsy- chosocial is more pragmatic and realistic. Keywords: physician-patient relations, clini- cal practice, theory, philosophy of medi- cine, history of medicine Alice laughed: Theres no use trying, She said; one cant believe impossible things. I daresay you havent had much prac- tice, said the Queen. When I was younger, I always did it for half an hour a day. Why, sometimes Ive believed as many as six impossible things before breakfast.Lewis Carroll, Alice in Wonderland We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the rst time. T. S. Eliot, Little Gidding, Four Quartets S ince the early descriptions of the bio- psychosocial model, practicing clini- cians have had difculty reconciling the biopsychosocial model with clinical reality (Borrell-Carrio, Suchman, & Epstein, 2004; Frankel, Quill, & McDaniel, 2003). As family physicians, we experience those difculties rst hand. We believe that these difculties are rooted in confusion about whether the biopsychosocial model is (a) a theory and therefore empirically ver- iable, (b) a philosophy and therefore logi- cally consistent, (c) a descriptive model to expand the scope of clinical inquiry, (d) a Ronald M. Epstein, MD, Rochester Center to Im- prove Communication in Health Care; Francesc Bor- rell-Carrio, MD, University of Barcelona and the Pri- mary Care Center La Gavarra, Cornella de Llobregat, Spain. Conceptualizations were by Drs. Epstein and Bor- rell-Carrio. The article was written by Dr. Epstein and revised and approved by Dr. Borrell-Carrio. We thank Ted Brown, PhD, for his careful reading and historical information. Correspondence concerning this article should be addressed to Ronald M. Epstein, MD, Professor of Family Medicine and Psychiatry, Rochester Center to Improve Communication in Health Care, 1381 South Avenue, Rochester, New York 14620. E-mail: ronald_epstein@urmc.rochester.edu Families, Systems, & Health Copyright 2005 by the Educational Publishing Foundation 2005, Vol. 23, No. 4, 426431 1091-7527/05/$12.00 DOI: 10.1037/1091-7527.23.4.426 426 belief system and therefore not subject to empirical proof, (e) a guide to practice and therefore with an implicit or explicit meth- odology, and/or (f) a vision of a way of prac- tice. We nd difculties in all six of these domains. In this article, we explore all six of these domains and the implications of applying a split model, as Herman (1989) suggested. We also propose that habits of mind may be the missing link between a biopsychosocial intent and clinical reality. In addition, we will argue that linear ap- proximationcircumscribed reduction- ismis often necessary to reafrm the model itself. As a theory, the biopsychosocial ap- proach includes a hierarchy of natural sys- tems and emphasis on the fact that subjec- tive experience is amenable to scientic in- quiry. But, the hierarchy of natural systems is an incomplete model; in some cases, it might not be a hierarchy, and not all levels are weighted equally in all situa- tions. Rather, the elements may be ar- ranged in different ways depending on the problem encountered. Consider the exam- ple of an adolescent with a sore throat. The relevant elements in one particular patient might include the cellular level (the bacte- rium or virus), the molecular level (the re- sulting inammation), and the social level (having to miss school), whereas the organ system level and dyadic levels might not be as relevant for him or her at this time. A diagram of this interaction and the relative importance of each element would look more like a matrix or a web rather than a linear ordering of levels. If the theory of a biopsychosocial approach rests on verica- tion of a linear hierarchical model, we will not nd convincing evidence that that model applies to all situations. Rather, the model should perhaps consist of matrices dened in part by who the patient is and in which situation he or she encounters him- self or herselfsensitivity to initial condi- tions in complexity theory (Plsek, 2001). Complex models may be difcult to justify without some degree of unquestioning be- lief in their truth. One of the difculties with philosophical movements is that adherents have a differ- ent set of experiences that led them to their espoused beliefs than the founders did. En- gel was rst a scientist, initially interested in reductionistic applications of laboratory concepts and methods but increasingly in- trigued by direct observation and clinical phenomenology. Through a set of personal realizations, the scope of his scientic in- quiry expanded to include application of the insights of psychoanalysis and atten- tiveness to the subjective dimensions of hu- man experience and interpersonal relation- ships (Brown, 2003). In his clinical role, he was, however, rarely limited by time. His well-deserved fame as a teacher came from his extraordinary capacity to observe as- tutely, be curious, and see the world through the patients eyes. He created an approach based on those observations, but it was a descriptive approach based on an evolved clinical interview and his skill in narrative storytelling. The logical consis- tency of a biopsychosocial approach is inti- mately tied up with who George Engel was as a person and his personal mission to establish scientic rigor in the eld of sub- jective human experience of health. Engels biopsychosocial model was a de- scriptive model to understand patients ill- ness experiences and, in that way, assist and expand the diagnostic process. Even as his career evolved, he was only secondarily interested in treatment. His classic devel- opmental study of Monica is a case in point; it was about experiment, observation, pre- diction, and description and much less about treatment, even though Engel and his team were deeply committed to Monica and invested in her successful development (Brown, 2003). Engels descriptions may not be quite complete enough to guide treatment. Considered as a belief system, the bio- psychosocial model provided an important corrective action to na ve psychosomatic SPECIAL ISSUE: BIOPSYCHOSOCIAL MODEL: SIX IMPOSSIBLE THINGS 427 approaches whose proponents proposed that unconscious conicts or life stress op- erated through simple mechanisms to cause physical illness. For others, however, biopsychosocial has a narrower connota- tion of nding psychological causes for physical illness, which ignores the more complex interactions that Engel empha- sized. Engels writings invite clinicians to see illness in a broader context that in- cludes but is not restricted to human sub- jective experience and to use all of their human capacities and clinical skills to un- derstand the way that subjective experi- ence is important in each clinical situation. As a guide to practice, Engel and his students and followers have developed clin- ical methods for communicating with pa- tients and engaging in clinical reasoning. However, the biopsychosocial approach sometimes is misunderstood to imply that specic behaviors, such as using empathic comments, being nice, or offering choices, are biopsychosocial. But, of course, empa- thy is meaningful only if used appropri- ately; empathy can be misplaced and thus seem false. Being nice, depending on the context, may not always be appropriate; one can simultaneously be nice, paternal- istic, and rigidly biomedical. Offering choices in an attempt to be empowering can also be misapplied; for example, patients with severe pain may require analgesia be- fore a meaningful relationship can be es- tablished and choices can be considered. Thus, it is difcult to specify particular be- haviors that are intrinsically biopsychoso- cial. Context and practical wisdom can guide the clinician in discerning which level of the spectrum is relevant for which problems and which responses might be meaningful to the patient. This takes prac- tice, critique, and mentorship. In our view, the most important contri- bution that Engel has given us is a vision that in health and illness, there is more than meets the untrained eye. He empha- sized over and over that subjective human experience is and should be a focus of sci- entic study, alongside and in equal impor- tance with reductionistic, mechanistic. and physical explanations of illness and suffer- ing. The timing of his 1977 article (Engel, 1977) coincided with a resurgent medical reductionism that was largely unopposed, and, in particular, was effecting a radical revision of psychiatry (Eisenberg, 1986). A new vision was needed to maintain, or re- constitute, a medical practice that could adequately address suffering. But to apply this vision, clinicians need practical wis- dom for guidance; knowledge and tech- niques are not sufcient (Davis, 1997). There is a danger, however. Even holistic visions can paradoxically degenerate into rigid orthodoxy that limits the ability of adherents to make and validate new obser- vations and to apply new therapeutic strategies. Linear approximations are often neces- sary to understand complex recursive sys- tems. One does not consider the theory of relativity when applying the brakes while driving. This is not only because attending to every level in every moment with every patient is bound to be overwhelming but also because linear approximations create frameworks that can inform a holistic view. The solution is not creating a narrower vi- sion. Rather, it is starting, as Engel em- phasizes, with the patients story. Patients experiences and accounts of illness are gen- erally not partitioned into biomedical and psychosocial domains; even the words bio- medical and psychosocial are not particu- larly meaningful from the perspective of a suffering person. Starting from an under- standing of this unpartioned overall expe- rience, the clinician can then develop a method for taking those pieces of the whole that are relevant for each case. Often the patient will tell the clinician which ele- ments those are, sometimes they will form a recognizable pattern based on prior expe- rience (Schmidt, Norman, & Boshuizen, 1990 ), and sometimes the review of sys- tems and mechanistic explanations may be helpful to survey of the terrain as long as 428 EPSTEIN AND BORRELL-CARRIO the clinician does not consider them synon- ymous with the entire clinical method. Starting with simplied models, the clini- cian can then expand these to view the whole situation in perspective. What practical lessons are we to gain from Engels wisdom? The rst is that, whatever the focus of the patients prob- lem, the clinician must adopt two types of visionrst, a direct vision of the problem unencumbered by categories, and second, a peripheral vision that can x on relevant data at the edges of the principal focus. Creating categories, if taken too seri- ously (e.g., the pancreatitis in room 403, the somatizer), limits the clinicians vi- sion. But, without categories, we are lost at sea and are diagnostically inept. One ap- proach to this conundrum is to adopt frag- ile categories, as William James suggested (James, 1975), in situations of clinical am- biguitynot taking our formulations as fact but rather as a way of structuring am- biguity and cultivating the ability to main- tain more than one perspective at the same time. Peripheral vision can take in various types of data for which the ones mind is preparedsocial data, psychological data, biomedical data, and laboratory data. But, some things are invisible to the unprepared mind. Preparation should include knowl- edge and experience and also adopting the curiosity that Engel exemplied in his in- teractions with patients; this curiosity should pervade the clinicians broad under- standing of the situation. Other fundamen- tal qualities are attentive observation and informed exibility. These qualities are teachable and can be reinforced. Second, there is a pressing need to re- ne teaching in medical school and resi- dency to emphasize not only clinical skills but also attitudes of mind, such as aware- ness of context and being-in-relation with the patient (Zoppi & Epstein, 2002). Train- ees should learn how, for example, a facil- itating comment in one context might be an interruption in another (Makoul, Rinta- maki, Epstein, Marvel, & Frankel, 1999; Marvel, Epstein, Flowers, & Beckman, 1999). Biopsychosocial training requires face-to-face human contact involving direct observation and critique by master clini- cians in the context of an apprenticeship or mentor-mentee relationshiprarities in current medical training (Ludmerer, 1999). Teachers need methods that are transpar- ent and pragmatic enough to reach stu- dents whose interpersonal skills are not necessarily well-developed on entry to medical school and adaptable to a variety of clinical settings. Student assessment programs set standards for clinician behav- ior; these should effectively identify and reward informed exibility, not just the completion of checklists (Epstein, in press). Fortunately, there has been progress since Hermans article 16 years ago. Courses in communication with patients are nearly universal in medical schools. In Rochester, we have developed exercises for students and residents in communicating evidence for informed decision making (Ep- stein, Alper, & Quill, 2004), building rela- tionships with families in busy primary care settings (McDaniel, Campbell, Hep- worth, & Lorenz, 2005), engaging in clini- cal reasoning that incorporates the pa- tients elicited values, and using reective questions to foster self-awareness and limit the likelihood of misunderstandings and errors (Borrell-Carrio & Epstein, 2004; Ep- stein, 2003). Collaborative work with men- tal health professionals is more common. Forward-looking student assessment pro- grams are designed to make it difcult to resolve clinical situations without synthe- sizing a wide array of relevant databio- medical, psychological, intersubjective, and ethological (Epstein et al., 2004). Practically speaking, what was lacking in the clinical encounter described by Dr. Herman was not that he delayed arriving at the diagnosis, but rather that he had not put himself in a position where he could listen and pursue relevant data, probably because of having made assumptions about SPECIAL ISSUE: BIOPSYCHOSOCIAL MODEL: SIX IMPOSSIBLE THINGS 429 what he would nd. These limiting as- sumptions were unexamined until after the diagnosis was made. Often, the reasons for not examining assumptions can be traced to psychological factors in the clinician fatigue, not wanting to face a possibility of more work, avoidance of difcult topics, and/or the desire for the patient to have a condition that the physician feels comfort- able treating (Borrell-Carrio & Epstein, 2004). In this case, perhaps the clinicians inner dialogue included thoughts such as, Shes complaining of fatigue like so many other patients, and its probably a psycho- logical condition like so many other pa- tients . . . . Cultivating self-awareness to examine those assumptions in an open, at- tentive, and curious way can help the cli- nician deconstruct categories that have be- come rigidied and less germane to the patients situation (Borrell-Carrio & Ep- stein, 2004; Epstein, 2003). This capacity for mindful in-the-moment self-monitoring may have been what was lacking in the case Dr. Herman describes but clearly was awakened once the diagnosis was reached. There are several methods for achieving self-awareness that can be incorporated into medical training (Borrell-Carrio & Ep- stein, 2004; Epstein, 2003; Novack, Ep- stein, & Paulsen, 1999; Novack, Kaplan, et al. 1997; Novack, Suchman, Clark, Ep- stein, Najberg, & Kaplan, 1997). This self- awareness takes no time for the prepared practitionerit is the marrow of daily practice. Preparation, though, requires at- tention, training, and calibration to de- velop habits of mind in approaching both novel and familiar situations (Novack, Suchman, et al., 1997). Mindful practice (Epstein, 1999)un- fettered total attention, critical curiosity, informed exibility, and presenceis best viewed as an asymptote that we never quite reach. It is an invitation for clinicians to know themselves better, including prej- udices, points of view, and blind spots. Ti- zon (1998) describes a biopsychosocial ap- proach to care as an impossible humanis- tic vision rather than an expectation that clinicians explore each level of the biopsy- chosocial hierarchy in each moment of each encounter. Rather than aspiring to being biopsychosocialsome imagined, static statethe ongoing process of becoming biopsychosocial develops mental supple- ness, diagnostic agility, thoughtful ap- proaches to therapeutics, and a holistic vi- sion; it provides a focus for nding meaning in clinical practice and pathways to strong relationships with patients. The dynamic tension exhibited in Her- mans article should not be dismissed glibly nor invite despair. Rather, it is an invita- tion to learn from unexpected (and not nec- essarily pleasant) moments of awareness. References Borrell-Carrio, F., & Epstein, R. M. (2004). Pre- venting errors in clinical practice: A call for self-awareness. Annals of Family Medicine, 2, 310316. Borrell-Carrio, F., Suchman, A. 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