Monday, September 5, 2011

Human Centered Health Home: Further Detecting 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

Let's continue using the Biopsychosocial Model to analyze the patient mentioned in the previous HCHH post about the BPSM  Using the BPSM for Detecting.  Many other models might also be applied to analyze the situation of patient and physician, but we're focusing on the Biopsychosocial Model (BPSM) developed by George Engel, MD, who was a psychiatrist 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 again 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).

We have analyzed many aspects of the situation using steps 1-5.  Now, we consider step 6: the patient himself.  In a typical office visit, I would usually use a human centered process and the biopsychosocial model to further detect patient alignment or misalignment with their best health.  Although the model is linear, the order of perusal depends on the situation defined by the particular visit, so I may start with step 4 or 5- community (since that's where the shared activities with my patient are and if that's where friends are considered as one uses the model) or family (if we have people whose friends are closer than family).

The personal relationship with the patient may be reaffirmed first as we seek a mutually beneficial outcome to this encounter that is health affirming/enhancing and relationship affirming/enhancing.  As a physician, I know that his health is more important than our friendship in the short run and the long run where our ethical sensitivity has to stay ever-vigilant, even with a friend, for situations that get near the boundary of ethically sensitive professional behavior.

We may talk about a shared activity that relates to a shared value.  It is best to use a positive situation, maybe the success of passing the school levy (but that might cause him to suddenly reflect on the negative aspects of the levy campaign and related stresses) or a more neutral comment such as how good the pep band sounded at the basketball game last Friday night, preparatory to getting the best information from him about his palpitations and the associated symptoms and contextual circumstances, noted in the 11/30/2010 post about the biopsychosocial model.  I know that I will bring up the stress associated with the school levy campaign, if he doesn't, because I'll get to assess how he's responding to a significant strain and stressor, which may be a factor in his palpitations.

He, my friend and patient, may inquire about me and my family or activities due to our friendship.  I know I have to be genuine in my responses and self disclosing and fully human (Can I turn off the physician and the clock, risking whatever that entails while I am his friend, allowing him to befriend me in the middle of physicianly activities and schedules?  To be the best Family Physician I can be, my human self has to be allowed to stay in the room, the friendship has to be in the room, the physician and physicianship has to be in the room.  The patient, also as human and friend is in the room.  Is it too crowded for all this?  It is an important dance.  That, friends, is at the heart of Family Medicine.  I love it.)

The physician role is then expanded as I transition into seeking clarification of his chief complaint- palpitations- through discourse and response to his comments and clarifying/ probing questions as needed.  As the visit evolves, I may reflect on MY OWN BPSM if my lead senses (visual, auditory and kinesthetic) seem to be inadequately connecting to the patient's life/BPSM.

The physician part of us is continually developing the differential diagnosis using a wide array of mental, mathematical and visual models as we flesh out the patient's story.  We should also continuously seek to clarify the meaning of the situation for the patient.  Getting the patient's perspective about perceived losses/gains resulting from the symptoms/situation is an important element in developing a goal for the patient. What is it they can't do, or fear the loss of,  as a result of the chief complaint?  What would they like to be able to do and when?  I've written about this process in the series on the Human Centered Health Home over the course of a year.  The differential diagnosis is a key piece in a physician's clinical thinking skills.  It cannot, however, be separate from the patient's life, goals and dreams in Family Medicine.

Using the Biopsychosocial Model to detect patient alignment or misalignment with their values, goals and dreams is part of the dance in Family Medicine.  We dance well but we may dance slow.  The natural history of many conditions and diseases, especially chronic diseases, is nicely aligned with the relationship-based nature of Family Medicine and our clinical problem solving and management skills.  No matter where the patient may weaken in their BPSM or need a congratulatory pat on the back or hug for an existing or regained strength, we are there if needed.  The BPSM helps us to remain aware of the strengths and needs of our patients.

As the Family Physician continues to relate to his patient's BPSM they will next relate to his nervous system, (step 7 in the model above) a great integrator, informer and deceiver.  Stay tuned, it will get even more complex as we move down the BPSM.

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