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Biopsychosocial
Aspects of Chronic
Medical Conditions
Psychological Aspects of
Chronic Illness
commonly overlooked
aspects of chronic illness
patients experience a decline in physical health
status and when patients experience stigma as a
result of:
  Increase self-care demands
Locus of Control &
Psychological Vulnerabilities
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
management of a chronic medical condition
chronic illness? Does chronic illness make us
vulnerable to experiencing psychological distress
that results in a psychological disorder?
Factors Impacting Chronic
Illness Management
ation influences their help-
seeking behaviors and is highly related to
a patient’s contact with health-service providers
impact that illness-related stress
can have on their illness-related symptomatology (i.e., stress
aggravates arthritic pain)
significant consequences on the
management of their disease (e.g., quit smoking in cancer
treatment or increased exercise in
Type 2 Diabetes)
health care system
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
chronic
medical conditions that are similar in severity
experience of the illness determines a
patients ability
to cope and manage the chronic medical condition. This affects:
-care behaviors
elp patients find the appropriate
framework for ascribing MEANING to their illness/symptoms
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
ceptions 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.
s perceptions is a key
component of
biopsychosocial interventions
Stress & Illness
with
chronic illnesses
symptomalotogy in chronic illness
biopsychosocial model of illness
week’s discussion-NIH Vcast Stress and Health: From
Molecules to Societies by Robert Sapolsky, Ph.D, Stanford
University:
Conclusions
we need to have a clear understanding of:
-
related symptomatology and management
omains 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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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
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 bi o-
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.
Biopsychosocial
View
of
Chronic
Illness
Incorpora)ng
Psychological,
Social,
&
Cultural
Factors
in
Chronic
Illness
Management
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
illnesses
are
among
the
most
prevalent,
costly,
and
preventable
health
problems
incredible
treatment
challenges
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
&
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
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
&
Wellness
in
the
experience
of
func)oning
at
level
where
an
individual’s
poten)al
is
maximized
(capable);
wellness
can
coexist
with
chronic
illness
Suffering,
&
S)gma
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
Biopsychosocial
model
is
an
extension
of
the
biomedical
and
psychosocial
models
allows
us
to
conceptualize
the
rela)onship
between
biological,
psychological,
social,
and
cultural
factors
in
chronic
illness
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
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
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.
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.

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Biopsychosocial Aspects of Chronic Medical Conditions

  • 1. Biopsychosocial Aspects of Chronic Medical Conditions Psychological Aspects of Chronic Illness commonly overlooked aspects of chronic illness patients experience a decline in physical health status and when patients experience stigma as a result of:   Increase self-care demands Locus of Control & Psychological Vulnerabilities need to be in control of their lives with the need
  • 2. to have significant others “take over” certain aspects of their life/care at times management of a chronic medical condition chronic illness? Does chronic illness make us vulnerable to experiencing psychological distress that results in a psychological disorder? Factors Impacting Chronic Illness Management ation influences their help- seeking behaviors and is highly related to a patient’s contact with health-service providers impact that illness-related stress can have on their illness-related symptomatology (i.e., stress aggravates arthritic pain) significant consequences on the
  • 3. management of their disease (e.g., quit smoking in cancer treatment or increased exercise in Type 2 Diabetes) health care system 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
  • 4. Disorder Somatization Psychological Adjustment chronic medical conditions that are similar in severity experience of the illness determines a patients ability to cope and manage the chronic medical condition. This affects: -care behaviors elp patients find the appropriate framework for ascribing MEANING to their illness/symptoms illness in light of pre-existing beliefs and assumptions about their world Illness Representation Themes Identity • Diagnostic
  • 5. 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
  • 6. • How the individual anticipates recovery from and control of the illness ceptions 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. s perceptions is a key component of biopsychosocial interventions Stress & Illness with chronic illnesses symptomalotogy in chronic illness
  • 7. biopsychosocial model of illness week’s discussion-NIH Vcast Stress and Health: From Molecules to Societies by Robert Sapolsky, Ph.D, Stanford University: Conclusions we need to have a clear understanding of: - related symptomatology and management omains 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 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 4 576
  • 8. 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 4 576 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-
  • 9. 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
  • 10. 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
  • 11. 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] 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 4 577 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
  • 12. 577 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 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-
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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 4 578 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 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-
  • 17. 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
  • 18. 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
  • 19. 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 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 4 579 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 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
  • 20. 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
  • 21. 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
  • 22. 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- 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 4 580 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
  • 23. AT E R 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-
  • 24. 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
  • 25. 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
  • 26. 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 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 4 581 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 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
  • 27. 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-
  • 28. 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 bi o- 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
  • 29. 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.
  • 30. 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
  • 31. 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.
  • 32. 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
  • 33. 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.
  • 34. 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
  • 35. 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
  • 36. 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;
  • 37. 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.