Tuesday, November 30, 2010

The Human Centered Health Home: Detecting Patient Alignment or Misalignment Using the Biopsychosocial Model

“The central tasks of a physician’s life are understanding illness and understanding people.  Because one cannot fully understand an illness without also understanding the person who is ill, these two tasks are indivisible.”…McWhinney in A Textbook of Family Medicine

In the Human Centered Health Home (HCHH), after the Respecting, Protecting, and Connecting processes are underway, the next process, as mentioned in the last HCHH blog post on 11/22/2010 is Detecting. I refer to it as detecting patient alignment and/or misalignment.  Many models might be applied to analyze the situation of patient and physician, including the Biopsychosocial Model (BPSM) developed by George Engel, MD, a cardiologist at the University of Rochester.

Please remember that the use of models may distort, delete and generalize information that is analyzed using the model.  The model is not the reality, but attempts to represent reality.
The biopsychosocial model is a linear heirarchy used to review an individual situation of a patient and even  a physician. From the biosphere to the subatomic level, what are the implications for the individual patient?

Biopsychosocial Model from George Engel
1. Biosphere                                 8.  Organs/ Organ System
2. Society/ Nation                      9.  Tissues
3. Culture/ Subculture               10. Cells
4. Community                             11. Organelles
5. Family                                       12. Molecules
6. Patient                                      13. Atoms
7. Nervous System                     14. Subatomic

Let's look at a 45 year old married, male high school principal who lives with his wife of 18 years and two teenage children (girl 15 and boy 13) in their home on the edge of the 5,000 person town in which is located the school that employs both of the adults.  He is seeing his family physician, with whom he has a long standing personal friendship and professional relationship, for palpitations (notable sense that the heart is beating- not supposed to be notable).

Using the model, we inquire of the patient or think about the possibility of the biosphere causing or relating to the palpitations, possibly from explosions on the surface of the Sun or the recent eclipse. Thinking of the Sun a while longer, we recall that Vitamin D3 is coming to our patient from the Sun and wonder if the decreased sunlight in the Ohio overcast fall weather could be a factor in the palpitations, recalling that a deficiency of Vitamin D3 can lead to heart attack, stroke, cancer of the breast, colon or prostate gland.  We will include a D3 level in the lab tests ordered later in the office visit.

Next in the model is consideration of the impact of the society and nation on the cardiovascular system of our patient with the heart palpitations.  The economy of the nation and the state is affecting the school system adversely, but the local society passed the school levy a few weeks ago, giving the principal breathing room in his budget for the next year.  The work culture changed as the teachers did threaten to strike and harsh words were exchanged between the principal and union leaders as the new budget was developed, including an intensely disappointing reduction in health benefits next year for all school employees, including the principal.

Worrying about the levy and loss of friendships affected the principal's sleep.  He also noted the blood pressure written down by the Medical Assistant was elevated at 144/92 and his weight was 20 pounds heavier than last year.  Even his pulse rate at 82 was higher than his resting pulse of 68 two years ago after the July 4th 5 mile run preparation got him in good shape. 
The subcultures of teachers and other school workers shifted to groups of strongly supportive and strongly opposed to the changes in the school system and employee benefits.  Student subcultures reflected parental attitudes regarding the levy and the proposed changes.  The tension seemed to lead to more student unrest and angry factions with increased fighting in the bleachers at football and basketball games.  More students and their parents were meeting with the principal than ever.

The local community was mostly business as usual except there was less of it due to the economic slowdown and increasing unemployment.  The principal often ate breakfast on Saturday mornings with his family at the locally owned restaurant which was popular for their whole hog sausage gravy and homemade biscuits, served with eggs, hash-brown potatoes and coffee.  Community members were friendly with them and engaged socially without mention of budgets or politics until one week before the election.  Then he and his wife only received polite inquiries about the financial facts of the school levy.

His family was supportive of his role as principal, but the two teens were getting flack from friends at school about why their dad wanted to get rid of teachers with seniority, a powerful rumor going around the school.  They pressed him for insider details at times so they could provide secret reassurances to their friends about the security of sports and extracurricular activities.  He politely informed them of the decision processes involved in school leadership and the need for some privacy as the school board considered delicate personnel issues.

His parents (his family of origin) were retired and living about 120 miles away in a senior living community.  His father had experienced a heart attack at the age or 68 and had a stent placed in his left carotid artery last year shortly before his 78th birthday.  Mom was politically active on the town council and took medicine for high blood pressure.  They both took medicine for high cholesterol and expressed their concern that their son enjoyed eggs too much.

This scenario represents how a physician may gather and analyze information about patient health and symptoms using the Biopsychosocial Model (BPSM).  We haven't gotten to the patient focused part yet, but we have some ideas about the context within which the heart palpitations occurred.  Note that the "medical" information is sparse so far, but look at the rest of the model above which will be heavily medical.  Usually, patients are driven to enter most clinical encounters at step 6, 7, or 8 , possibly avoiding the type of information we have gathered from this patient using the BPSM.

We'll start with step 6 in the next HCHH blog post, continuing to analyze the principal's palpitations.  A lot of information contributes to clinical decision making and the BPSM is one way to stimulate an expansion of the types of information gathered.  Stay tuned (and watch out for whole hog sausage gravy).


  1. Wow. No wonder I'm so tired every day! What a great summary of the complexities of family medicine. I get tired of people thinking it is all runny noses and sprained ankles. Every patient has to be looked at as a whole person, not a complex of symptoms and we have to take into consideration their environment. Every single one. It is work to be a great FP. Very rewarding work, but WORK.

  2. Absolutely the best summary application of the BPSM that I've seen!!!

  3. Fascinating. I had no idea. It sounds like the "small talk" that I dread so much is actually part of the information gathering process.

  4. Thanks for your comments. Dr F To F, Indeed we are involved in a complex endeavor that is challenging, tiring at times, and rewarding.

    Cheryl, I'm flattered by your BPSM comment. Thanks

    WS, Right on about "small talk". Every word has meaning. Human interaction is fascinating and unique, especially in patient - physician interactions.