The Need for a New Medical Model: A Challenge for Biomedicine
Engel GL.
Science. 1977 Apr 8; 196(4286):129-36.
Abstract
The dominant model of disease today is biomedical, and it leaves no room within tis framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.
需要新的医学模型-对生物医学的挑战
〔美〕恩格尔 黎风 摘译
http://blog.sciencenet.cn/blog-738133-681633.html
作者为美国纽约罗彻斯特大学医学院精神病学和医学教授。
出处：Engel GL: The need for a new medical model: a challenge forbiomedicine. Science 1977;196:129–136
引用：L 恩格尔.需要新的医学模型:对生物医学的挑战[J].医学与哲学,1980 ,1 (3) :88.
生物医学模型
今天占统洽地位的疾病模型是生物医学模型，分子生物学是它的基本学科。这种模型认为疾病完全可以用偏离正常的可测量的生物学（躯体）变量来说明。
在它的框架内没有给病的社会、心理和行为方面留下余地。生物医学模型不仅要求把疾病视为独立于社会行为的实体, 而且要求根据躯体（生化或神经生理）过程的紊乱来解释行为的障碍。因此, 生物医学模型既包括还原论, 即最终从简单的基本的原理中推导出复杂现象的哲学观点, 又包括心身二元论, 即把精神的东西同身体的东西分开的学说。在这里还原论的基本原理是物理主义原理, 即它认为化学和物理学的语言最终足以解释生物学现象。从还原论观点看, 表征和研究生物学系统的唯一概念工具和实验工具本质上是物理学的。
在我们的文化中, 早在医生们开始受职业教育以前, 他们的态度和信仰系统就受到生物医学模型的影响。因此这种模型已成为一种文化上的至上命令, 它的局限性易受忽视。简言之,它现在已获得教条的地位。
在科学中, 当一个模型不能适宜地解释所有资料时, 就要修改或摈弃这个模型。而教条则要求不一致的资料勉强适应模型或对这些资料干脆排斥不管。生物医学教条要求包括“精神病”在内的所有疾病用物理机制的紊乱来理解。
结果只有两种办法才能把疾病和行为调和起来：一种是还原论的办法, 它说疾病的一切行为现象必须用物理化学原理来理解, 另一种是排外主义的办法, 它说任何不能作如此解释的必须从疾病范畴中排除出去。在医生和精神病学家中,还原论者和排外主义者鄙视那些敢于向生物医学模型的终极真理提出疑问和主张建立一个更有用的模型的人为异端。
还原论生物医学模型的历史根源
为什么还原论的、二元论的生物医学模型在西方发展起来？拉斯莫森认为原因之一是当年基督教会准许解剖人体时仍坚持把身体视为灵魂从这个世界转移到另一世界的容器的观点。当时准许解剖人体有一个君子协定, 不许对人的精神和行为进行科学研究, 因为教会认为人的精神和行为与宗教和灵魂更有关系, 因而是属于它的领域。这种协定对科学的西方医学终于建立于其上的解剖和结构基础有很大影响。
同时, 由伽利略、牛顿和笛卡儿阐明的科学基本原理是分析的, 意即研究的实体应被分解为可分离的因果链条或单元, 因此认为无论是在物质上和概念上整体可通过重组部分来理解。
随着心身二元论在教会认可下牢固地树立起来, 古典科学推进了这样一些观念：身体是机器, 疾病是机器故障的结果, 医生的任务是修理机器。因此对疾病的科学研究方法一开始就用部分、分析法集中于生物学（躯体）的过程, 而忽视行为和心理学的过程。许多医生的实践就是如此。至少在20世纪初以前, 即使他们认为情绪对疾病的发展和进程很重要。对疾病的生物医学研究法取得了意料之外的成功, 但也付出了代价, 因为它造成了许多问题。
生物医学模型的局限性
我们现在面临这样一种需要和挑战：扩充对疾病的研究方法, 把心理学的研究方法也包括进去, 同时不牺牲生物医学研究方法的巨大优点。
凯蒂把糖尿病和精神分裂症作为躯体病和精神病的范例加以比较。“这两种疼病都是一组症状或综合征, 一个用驱体的和生化的异常来描述, 另一个用心理的异常来描述。每一种疾病都有许多病因, 强度范围从严重致虚弱到潜伏或难以确定。也有证据表明在这两种疚病的发展中遗传的和环境的作用都起作用。”至少用还原论术语作描述时, 糖尿病的科学表征更为先进：它已从症状的行为结构进展到生化异常的行为结构。
归根到底, 还原论认为精神分裂症也要这样解决。凯蒂说他不认为在精神分裂症中现在已知存在的（或将来可被发现的）遗传因素和生物学过程在病因学中是唯一重要的影响。
他坚持认为同样重要的是要阐明“经验因素及其与生物学易感性的相互作用”如何成为可能, 或如何预防精神分裂症的发展。
对新的医学模型的要求
（1）在生物医学模型中, 特异性生化偏差一般被认为是疾病的特异性诊断标准。然而根据人生病的经验, 实验室检查结果也许仅表明有潜在的疾病, 那时实际上没有病。异常是存在的, 但病人没有病。因此糖尿病或精神分裂症生化缺陷的存在充其量规定了人类生病的一个必要条件，而不是一个充分条件。更确切地说，生化缺陷只不过是许多因素中间的一个, 生病是这许多因素的相互作用达到顶点所致。生化缺陷也不能用来说明病的一切, 因为完全的理解还要求其他的概念和参考系。因此糖尿病的诊断首先由某些核心的临床表现（如多尿、多饮、多食、体重丧失等）提示的, 然后为实验室检查出胰岛素相对缺乏所证实, 但这些如何被某个人经验到、报告出来, 这些如何影响他, 这一切要求心理学、社会和文化因素的考虑。
（2）在特殊的生化过程与病的临床资料之间建立一种联系, 要求用科学上合理的方法来研究行为和心理社会资料, 因为这些资料是病人用来报告大多数临床现象的术语。生物医学模型忽视病人的口述, 主要依靠技术程序和实验室测定。临床资料和实验资料之间相关的考查不仅要求有收集临床资料的可靠方法, 高水平的问诊技能, 而且要求对病人如何把疾病的症状联系起来的心理学、社会和文化决定因素有基本理解。例如许多口头的表达导源于生活早期的体验, 因此病人用来报告症状的语言是十分含糊的。
（3）糖尿病和精神分裂症有个共同点：生活条件是影响疾病发作时间以及病程变化的重要变量。
对生活变化的心理生理反应可与现存的躯体因素相互作用以改变易感性, 从而影响疾病发作时间、严重程度和进程。
（4）决定具有糖尿病和精神分裂症生化异常的人是否和何时认为自己或被别人认为是病人, 心理和社会因素在其中也是关键性的。生化缺陷可决定疾病的某些特征, 但并不一定决定该人成为病人或处于病人地位。
（5）仅仅针对生化异常的“合理治疗”不一定使病人恢复健康, 即使异常已得到纠正或改善。显然生化异常的纠正和治疗结局之间的这种差异是由于心理和社会变量所致。
（6）即使是应用合理治疗，医生的行为和病人与医生之间的关系也有力地影响治疗结局，或更好一些，或更坏一些。例如糖尿病人对胰岛素的需要量变化很大, 随病人对他与医生的关系如何感觉而异。
生物心理社会模型的优点
为了理解疾病的决定因素以及到达合理的治疗和卫生保健模式, 医学模型必须也考虑到病人, 病人在其中生活的环境以及由社会设计来对付病的破坏作用的补充系统, 即医生的作用和卫生保健制度。这就要求一种生物心理社会模型。
传统的生物医学观点认为生物学指标是决定疾病的最终标准, 会导致目前的矛盾：某些人实验室检查结果是阳性, 说他们需要治疗, 而事实上他们感到很好, 而感到有病的人却说他们没有病。生物心理社会模型包括病人和病, 也包括环境。对于一个焦虑不安和机能障碍的病人, 医生必须考虑社会和心理因素以及生物学因素所起的相对作用, 这些因素既包含在病人的焦虑不安和机能障碍中, 也包含在病人决定是否承认自己是病人和是否承担在治疗中有合作的责任之中。
对医学和精神病学都是挑战
生物心理社会医学模型的提出对医学和精神病学都是一个挑战。因为尽管生物医学的成就巨大, 在公众以及医生中, 尤其是年青一代中对保健的需要不能满足, 生物医学对人类的影响不大日益感到不安。通常把这种情况归因于现存卫生制度不适宜。医学机构被认为是冷酷的和不近人情的。作为生物医学中心的这些机构威望越高，这种抱怨越多。许多医生的生物医学基础知识很好, 但医治病人必不可少的品质很差。许多人承认单单在生物医学模型范围内这些是不能改善的。
霍夫曼把不必要的住院、滥用药物、过多的手术和不适当的使用诊断试验直接归因于生物医学还原论和它的支持者对卫生保健系统的统治。不自觉地赞成生物医学模型并分裂为还原论者和排外主义者两个阵营的精神病学家不认识精神病学是医学中主要研究人及其条件的唯一临床学科。过去30年对更为整合和整体的健康和疾病概念的表述, 主要是由利用起源于精神病学的概念和方法的医生提出的, 尤其是弗洛伊德的心理动力学方法和心理分析, 以及梅耶的生活应激反应方法和心理生物学。他们的贡献是提供了一个把心理过程包括在疾病概念内的参考系。心身医学——这个术语本身是二元论的残余——成为跨越医学两个平行的、独立的思想体系（生物学的和心理社会的）之间鸿沟的中介。
一般系统理论观点
使心理社会的东西和生物学中的东西在医学中和谐一致的斗争, 与受分子生物学的还原论方法统治的生物学有类似之处。生物学家中有人主张既要发展生命过程的还原论解释, 也要发展生命过程的整体论解释,既要回答“如何”的问题, 也要回答“为什么”的问题。
贝特朗斐为了开辟整体论研究法的道路, 提出了一般系统理论。这种方法把一组有关的事件综合起来看作是表现整体水平的功能和性质的系统, 这就有可能通过不同组织的层次,如分子、细胞、器官、机体、人、家庭、社会或生物圈来认识同形性。
从这些同形性中可以提出在各组织层次共同起作用和基本定律和原理。因为系统理论认为所有的组织层次在等级系统关系中是相互联系的, 因此一个层次中的变化就会影响另一层次的变化, 采纳系统理论作为科学方法将会大大缓和整体论和还原论的分裂, 促进科学学科间的渗透。对于医学, 系统理论提供了一个不仅适合于疾病的生物心理社会的概念, 而且适合于把疾病和医疗保健作为相互关联的过程来研究的概念方法。当一般系统方法成为未来医生和医学科学家基本的科学和哲学教育时, 可以预期对疾病的生物心理社会观点就更易容纳了。生物心理社会模型为研究、教学结构和卫生保健的行动计划提供了一个蓝图。
Biopsychosocial Challenges of the New Millennium
Ryff C.D. · Singer B.H.
Psychother Psychosom 2000;69:170–177
The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry
GEORGE ENGEL’S LEGACY
The 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 biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized 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, reductionistic, and specialized endeavor to become more contextual and cross-disciplinary.2–4 Engel did not deny that the mainstream of biomedical research had fostered important advances in medicine, but he criticized its excessively 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 scientific study. Engel championed his ideas not only as a scientific 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 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 relationship 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 evidence-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 biomedical model, with its separation of body and mind (which is popularly, but perhaps inaccurately, traced to Descartes).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 scientific clinician’s attention. Engel rejected this view for encouraging physicians to maintain a strict separation between the body-as-machine and the narrative 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 developmental effects on the whole organism.
Second, Engel criticized the excessively materialistic and reductionistic orientation of medical thinking. According to these principles, anything that could not be objectively verified and explained at the level of cellular and molecular processes was ignored or devalued. The main focus of this criticism—a cold, impersonal, technical, biomedically-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 seminal 1980 article on the clinical application of the biopsychosocial 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 influence 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 cannot 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 legitimate focus for scientific study.
Engel’s perspective is contrasted with a so-called monistic or reductionistic view, in which all phenomena could be reduced to smaller parts and understood as molecular interactions. Nor did he endorse a holistic-energetic view, many of whose adherents espouse a biopsychosocial philosophy; these views hold that all physical phenomena are ephemeral and controllable 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 different levels of the biopsychosocial hierarchy could interact, 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 conditions with which they were presented, much as large weather patterns can depend on initial conditions and small influences.9This perspective has guided decades of research seeking to elucidate the nature of these interactions.
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 contain 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 arthritis; both obesity and arthritis limit exercise capacity, adversely affecting blood pressure and cholesterol levels; and all of the above, except perhaps arthritis, contribute 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 observations set the stage for models of circular causality, which describes how a series of feedback loops sustain a specific pattern of behavior over time.10–13 Complexity science is an attempt to understand these complex recursive and emergent properties of systems14,15 and to find 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 necessary cause for tuberculosis is a mycobacterium, precipitants 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 hypertensive because he consumes too much salt, has a stressful 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 consume 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 myocardial 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 fight, 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-centered 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, finding out about the patient’s expectations, and exhorting the health professional to show the patient a human face. These approaches represent movement toward an egalitarian 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 complain 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 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 proactive 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 clinician must acknowledge and then transcend the tendency to label patients as “those with whom I get along well” or “difficult 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 sufficient 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 decisions 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 clinician 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.45Sometimes 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 transformation—the physician must first understand and accommodate 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 process to which the patient has not consented and may not desire. This debate, however, becomes much more difficult 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 physician 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 influence 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, understanding, generosity, and caring.
THE BIOPSYCHOSOCIAL MODEL AND RELATIONSHIP-CENTERED CARE
The practical application of the biopsychosocial model, which we will call biopsychosocially oriented clinical practice 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 fundamental 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, trustworthiness, and openness.49,50 Some principles of biopsychosocial-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 musical 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, gathering 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 find out what concerns the patient, but to bring the physician’s agenda to the table and influence 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 flexibility, and presence—underlies the physician’s ability to self-monitor, 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 cordiality, optimism, genuineness, and good humor. By receiving a hostile patient with respect,55 it clarifies for the clinician that the patient’s emotions are the patient’s—and not the physician’s—and also sets the stage for the patient to reflect 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 clinician seeing the patient for the first 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 legitimize their suffering by describing illnesses that make the clinician feel comfortable or confident.58
Recognizing Bias
The grounding of medical decisions based on scientific 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 scientific 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 tendency 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 difficult to track on a strictly cognitive level. If a clinician, encountering a situation in which he normally would use a particular 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 discarded, 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 obligation that the clinician use all of his or her capabilities, 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 physician 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 influence 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 reflective participation, thus infusing care with greater warmth and caring. The biopsychosocial model was not so much a paradigm shift—in the sense of a crisis of the scientific method in medicine or the elaboration of new scientific 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 first proposed the biopsychosocial model, two new intellectual 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 knowledge 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 thinking and action in helpful ways (eg, they contribute to health, well-being, and efficient use of resources), but when taken too literally, they can also entrap and limit us by creating boundaries that need not exist. By maintaining 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 flexible, out-of-the-box thinking.
Second, we can move beyond the multidimensional and multifactorial linear thinking to consider complexity theory as a more adequate model for understanding causality, dualism, and participation in care. Complexity theory shows how, in open systems, it is often impossible to know all of the contributors to and influences 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 buffers the tendency to impose unrealistic expectations that one can know and control all of these contributors and influences.65
George Engel’s most enduring contribution was to broaden the scope of the clinician’s gaze. His bio-psychosocial model was a call to change our way of understanding the patient and to expand the domain of medical knowledge to address the needs of each patient. It is perhaps the transformation of the way illness, suffering, and healing are viewed that may be Engel’s most durable contribution.
Acknowledgments
The following people have provided important critiques 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.
