biopsicosocial model explorando 6 cosas imposibles.pdf

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The Biopsychosocial Model:

Exploring Six Impossible Things

RONALD M. EPSTEIN, MD

FRANCESCBORRELL-CARRIO, MD

In our view, the biopsychosocial model is a

vision and an approach to practice rather

than an empirically verifiable theory, a co-

herent philosophy, or a clinical method. In

some cases, when that vision is confused

with ideologic dogmatism, it can invite

abandonment of the vision entirely or in

selected situations. The authors suggest

that habits of mind may be the missing link

between a biopsychosocial intent and clini-

cal reality. These habits of mind includeattentiveness, peripheral vision, curiosity,

and informed flexibility. These qualities are

teachable and can be reinforced. Rather

than aspiring to being biopsychosocial

some imagined, static statecommitment

to an ongoing process of becoming biopsy-

chosocial is more pragmatic and realistic.

Keywords:physician-patient relations, clini-

cal practice, theory, philosophy of medi-cine, history of medicine

Alice laughed: Theres no use trying,She said; one cant believe impossiblethings.I daresay you havent had much prac-tice, said the Queen. When I wasyounger, I always did it for half an houra day. Why, sometimes Ive believed as

many as six impossible things beforebreakfast.Lewis Carroll, Alice inWonderland

We shall not cease from explorationAnd the end of all our exploringWill be to arrive where we started

And know the place for the first time.T. S. Eliot, Little Gidding, FourQuartets

Since the early descriptions of the bio-psychosocial model, practicing clini-cians have had difficulty reconciling thebiopsychosocial model with clinical reality(Borrell-Carrio, Suchman, & Epstein,2004; Frankel, Quill, & McDaniel, 2003).

As family physicians, we experience thosedifficulties first hand. We believe thatthese difficulties are rooted in confusionabout whether the biopsychosocial model is

(a) a theory and therefore empirically ver-ifiable, (b) a philosophy and therefore logi-cally consistent (c) a descriptive model to

Ronald M. Epstein, MD, Rochester Center to Im-prove Communication in Health Care; Francesc Bor-rell-Carrio, MD, University of Barcelona and the Pri-mary Care Center La Gavarra, Cornella de Llobregat,Spain.

Conceptualizations were by Drs. Epstein and Bor-rell-Carrio. The article was written by Dr. Epsteinand revised and approved by Dr. Borrell-Carrio.

We thank Ted Brown, PhD, for his careful readingand historical information.

Correspondence concerning this article should beaddressed to Ronald M. Epstein, MD, Professor ofFamily Medicine and Psychiatry, Rochester Center toImprove Communication in Health Care, 1381 SouthA R h t N Y k 14620 E il

Families, Systems, & Health Copyright 2005 by the Educational Publishing Foundation2005, Vol. 23, No. 4, 426 431 1091-7527/05/$12.00 DOI: 10.1037/1091-7527.23.4.426


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belief system and therefore not subject toempirical proof, (e) a guide to practice andtherefore with an implicit or explicit meth-odology, and/or (f) a vision of a way of prac-tice. We find difficulties in all six of these

domains. In this article, we explore all sixof these domains and the implications ofapplying a split model, as Herman (1989)suggested. We also propose that habits ofmind may be the missing link between abiopsychosocial intent and clinical reality.In addition, we will argue that linear ap-proximationcircumscribed reduction-ismis often necessary to reaffirm themodel itself.

As a theory, the biopsychosocial ap-proach includes a hierarchy of natural sys-tems and emphasis on the fact that subjec-tive experience is amenable to scientific in-quiry. But, the hierarchy of naturalsystems is an incomplete model; in somecases, it might not be a hierarchy, and notall levels are weighted equally in all situa-tions. Rather, the elements may be ar-ranged in different ways depending on theproblem encountered. Consider the exam-ple of an adolescent with a sore throat. Therelevant elements in one particular patientmight include the cellular level (the bacte-rium or virus), the molecular level (the re-sulting inflammation), and the social level(having to miss school), whereas the organsystem level and dyadic levels might not beas relevant for him or her at this time. A

diagram of this interaction and the relativeimportance of each element would lookmore like a matrix or a web rather than alinear ordering of levels. If the theory of abiopsychosocial approach rests on verifica-tion of a linear hierarchical model, we willnot find convincing evidence that thatmodel applies to all situations. Rather, themodel should perhaps consist of matricesdefined in part by who the patient is and in

which situation he or she encounters him-self or herselfsensitivity to initial condi-tions in complexity theory (Plsek 2001)

without some degree of unquestioning be-lief in their truth.

One of the difficulties with philosophicalmovements is that adherents have a differ-ent set of experiences that led them to their

espoused beliefs than the founders did. En-gel was first a scientist, initially interestedin reductionistic applications of laboratoryconcepts and methods but increasingly in-trigued by direct observation and clinicalphenomenology. Through a set of personalrealizations, the scope of his scientific in-quiry expanded to include application ofthe insights of psychoanalysis and atten-tiveness to the subjective dimensions of hu-

man experience and interpersonal relation-ships (Brown, 2003). In his clinical role, hewas, however, rarely limited by time. Hiswell-deserved fame as a teacher came fromhis extraordinary capacity to observe as-tutely, be curious, and see the worldthrough the patients eyes. He created anapproach based on those observations, butit was a descriptive approach based on anevolved clinical interview and his skill in

narrative storytelling. The logical consis-tency of a biopsychosocial approach is inti-mately tied up with who George Engel wasas a person and his personal mission toestablish scientific rigor in the field of sub-

jective human experience of health.Engels biopsychosocial model was a de-

scriptive model to understand patients ill-ness experiences and, in that way, assistand expand the diagnostic process. Even as

his career evolved, he was only secondarilyinterested in treatment. His classic devel-opmental study of Monica is a case in point;it was about experiment, observation, pre-diction, and description and much lessabout treatment, even though Engel andhis team were deeply committed to Monicaand invested in her successful development(Brown, 2003). Engels descriptions maynot be quite complete enough to guide

treatment.Considered as a belief system, the bio-psychosocial model provided an important

SPECIAL ISSUE: BIOPSYCHOSOCIAL MODEL: SIX IMPOSSIBLE THINGS 427


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approaches whose proponents proposedthat unconscious conflicts or life stress op-erated through simple mechanisms tocause physical illness. For others, however,biopsychosocial has a narrower connota-

tion of finding psychological causes forphysical illness, which ignores the morecomplex interactions that Engel empha-sized. Engels writings invite clinicians tosee illness in a broader context that in-cludes but is not restricted to human sub-

jective experience and to use all of theirhuman capacities and clinical skills to un-derstand the way that subjective experi-ence is important in each clinical situation.

As a guide to practice, Engel and hisstudents and followers have developed clin-ical methods for communicating with pa-tients and engaging in clinical reasoning.However, the biopsychosocial approachsometimes is misunderstood to imply thatspecific behaviors, such as using empathiccomments, being nice, or offering choices,are biopsychosocial. But, of course, empa-thy is meaningful only if used appropri-

ately; empathy can be misplaced and thusseem false. Being nice, depending on thecontext, may not always be appropriate;one can simultaneously be nice, paternal-istic, and rigidly biomedical. Offeringchoices in an attempt to be empowering canalso be misapplied; for example, patientswith severe pain may require analgesia be-fore a meaningful relationship can be es-tablished and choices can be considered.

Thus, it is difficult to specify particular be-haviors that are intrinsically biopsychoso-cial. Context and practical wisdom canguide the clinician in discerning whichlevel of the spectrum is relevant for whichproblems and which responses might bemeaningful to the patient. This takes prac-tice, critique, and mentorship.

In our view, the most important contri-bution that Engel has given us is a vision

that in health and illness, there is morethan meets the untrained eye. He empha-sized over and over that subjective human

entific study, alongside and in equal impor-tance with reductionistic, mechanistic. andphysical explanations of illness and suffer-ing. The timing of his 1977 article (Engel,1977) coincided with a resurgent medical

reductionism that was largely unopposed,and, in particular, was effecting a radicalrevision of psychiatry (Eisenberg, 1986). Anew vision was needed to maintain, or re-constitute, a medical practice that couldadequately address suffering. But to applythis vision, clinicians need practical wis-dom for guidance; knowledge and tech-niques are not sufficient (Davis, 1997).There is a danger, however. Even holistic

visions can paradoxically degenerate intorigid orthodoxy that limits the ability ofadherents to make and validate new obser-

vations and to apply new therapeuticstrategies.

Linear approximations are often neces-sary to understand complex recursive sys-tems. One does not consider the theory ofrelativity when applying the brakes whiledriving. This is not only because attending

to every level in every moment with everypatient is bound to be overwhelming butalso because linear approximations createframeworks that can inform a holistic view.The solution is not creating a narrower vi-sion. Rather, it is starting, as Engel em-phasizes, with the patients story. Patientsexperiences and accounts of illness are gen-erally not partitioned into biomedical andpsychosocial domains; even the words bio-

medical and psychosocial are not particu-larly meaningful from the perspective of asuffering person. Starting from an under-standing of this unpartioned overall expe-rience, the clinician can then develop amethod for taking those pieces of the wholethat are relevant for each case. Often thepatient will tell the clinician which ele-ments those are, sometimes they will forma recognizable pattern based on prior expe-

rience (Schmidt, Norman, & Boshuizen,1990 ), and sometimes the review of sys-tems and mechanistic explanations may be

428 EPSTEIN AND BORRELL-CARRIO


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the clinician does not consider them synon-ymous with the entire clinical method.Starting with simplified models, the clini-cian can then expand these to view thewhole situation in perspective.

What practical lessons are we to gainfrom Engels wisdom? The first is that,whatever the focus of the patients prob-lem, the clinician must adopt two types of

visionfirst, a direct vision of the problemunencumbered by categories, and second, aperipheral vision that can fix on relevantdata at the edges of the principal focus.

Creating categories, if taken too seri-ously (e.g., the pancreatitis in room 403,

the somatizer), limits the clinicians vi-sion. But, without categories, we are lost atsea and are diagnostically inept. One ap-proach to this conundrum is to adopt frag-ile categories, as William James suggested(James, 1975), in situations of clinical am-biguitynot taking our formulations asfact but rather as a way of structuring am-biguity and cultivating the ability to main-tain more than one perspective at the same

time.Peripheral vision can take in various

types of data for which the ones mind ispreparedsocial data, psychological data,biomedical data, and laboratory data. But,some things are invisible to the unpreparedmind. Preparation should include knowl-edge and experience and also adopting thecuriosity that Engel exemplified in his in-teractions with patients; this curiosity

should pervade the clinicians broad under-standing of the situation. Other fundamen-tal qualities are attentive observation andinformed flexibility. These qualities areteachable and can be reinforced.

Second, there is a pressing need to re-fine teaching in medical school and resi-dency to emphasize not only clinical skillsbut also attitudes of mind, such as aware-ness of context and being-in-relation with

the patient (Zoppi & Epstein, 2002). Train-ees should learn how, for example, a facil-itating comment in one context might be an

maki, Epstein, Marvel, & Frankel, 1999;Marvel, Epstein, Flowers, & Beckman,1999). Biopsychosocial training requiresface-to-face human contact involving directobservation and critique by master clini-

cians in the context of an apprenticeship ormentor-mentee relationshiprarities incurrent medical training (Ludmerer, 1999).Teachers need methods that are transpar-ent and pragmatic enough to reach stu-dents whose interpersonal skills are notnecessarily well-developed on entry tomedical school and adaptable to a varietyof clinical settings. Student assessmentprograms set standards for clinician behav-

ior; these should effectively identify andreward informed flexibility, not just thecompletion of checklists (Epstein, in press).

Fortunately, there has been progresssince Hermans article 16 years ago.Courses in communication with patientsare nearly universal in medical schools. InRochester, we have developed exercises forstudents and residents in communicatingevidence for informed decision making (Ep-

stein, Alper, & Quill, 2004), building rela-tionships with families in busy primarycare settings (McDaniel, Campbell, Hep-worth, & Lorenz, 2005), engaging in clini-cal reasoning that incorporates the pa-tients elicited values, and using reflectivequestions to foster self-awareness and limitthe likelihood of misunderstandings anderrors (Borrell-Carrio & Epstein, 2004; Ep-stein, 2003). Collaborative work with men-

tal health professionals is more common.Forward-looking student assessment pro-grams are designed to make it difficult toresolve clinical situations without synthe-sizing a wide array of relevant databio-medical, psychological, intersubjective,and ethological (Epstein et al., 2004).

Practically speaking, what was lackingin the clinical encounter described by Dr.Herman was not that he delayed arriving

at the diagnosis, but rather that he had notput himself in a position where he couldlisten and pursue relevant data probably



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what he would find. These limiting as-sumptions were unexamined until after thediagnosis was made. Often, the reasons fornot examining assumptions can be tracedto psychological factors in the clinician

fatigue, not wanting to face a possibility ofmore work, avoidance of difficult topics,and/or the desire for the patient to have acondition that the physician feels comfort-able treating (Borrell-Carrio & Epstein,2004). In this case, perhaps the cliniciansinner dialogue included thoughts such as,Shes complaining of fatigue like so manyother patients, and its probably a psycho-logical condition like so many other pa-

tients . . . . Cultivating self-awareness toexamine those assumptions in an open, at-tentive, and curious way can help the cli-nician deconstruct categories that have be-come rigidified and less germane to thepatients situation (Borrell-Carrio & Ep-stein, 2004; Epstein, 2003). This capacityfor mindful in-the-moment self-monitoringmay have been what was lacking in thecase Dr. Herman describes but clearly was

awakened once the diagnosis was reached.There are several methods for achievingself-awareness that can be incorporatedinto medical training (Borrell-Carrio & Ep-stein, 2004; Epstein, 2003; Novack, Ep-stein, & Paulsen, 1999; Novack, Kaplan, etal. 1997; Novack, Suchman, Clark, Ep-stein, Najberg, & Kaplan, 1997). This self-awareness takes no time for the preparedpractitionerit is the marrow of daily

practice. Preparation, though, requires at-tention, training, and calibration to de-

velop habits of mind in approaching bothnovel and familiar situations (Novack,Suchman, et al., 1997).

Mindful practice (Epstein, 1999)un-fettered total attention, critical curiosity,informed flexibility, and presenceis best

viewed as an asymptote that we neverquite reach. It is an invitation for clinicians

to know themselves better, including prej-udices, points of view, and blind spots. Ti-zon (1998) describes a biopsychosocial ap-

tic vision rather than an expectation thatclinicians explore each level of the biopsy-chosocial hierarchy in each moment of eachencounter. Rather than aspiring to beingbiopsychosocialsome imagined, static

statethe ongoing process of becomingbiopsychosocial develops mental supple-ness, diagnostic agility, thoughtful ap-proaches to therapeutics, and a holistic vi-sion; it provides a focus for finding meaningin clinical practice and pathways to strongrelationships with patients.

The dynamic tension exhibited in Her-mans article should not be dismissed gliblynor invite despair. Rather, it is an invita-

tion to learn from unexpected (and not nec-essarily pleasant) moments of awareness.

References

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R. M. (2004). The biopsychosocial model 25

years later: Principles, practice, and scien-tific inquiry. Annals of Family Medicine, 2,576582.

Brown, T. (2003). George Engel and Rochestersbiopsychosocial tradition: Historical and de-velopmental perspectives. In R. M. Frankel,T. E. Quill, & S. H. McDaniel (Eds.), The

Biopsychosocial Approach: Past, Present, Fu-ture (pp. 199218). Rochester, NY: Univer-sity of Rochester Press.

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Epstein, R. M., Alper, B. S., & Quill, T. E.(2004). Communicating evidence for partici-patory decision making.JAMA: The Journalof the American Medical Association, 291,23592366.

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