The biopsychosocial model and patient centered clinical method

Prepared by Dr. Laila T. Sabei

2015-2016
In clinical medicine, there are two models to understand health, disease and
illness; the first is the traditional biomedical model which focus on
pathophysiologyand other biological approaches todisease, the second is the
biopsychosocial model which considers biological, psychological, and
social factors andtheir complex interactions in understanding health and
illness.

In the old biomedical model: A disease can be viewed independently from

the person who is suffering from it and from his social context. Mental and
physical diseases can be considered separately, with provision for a group of
psychosomatic diseases in which the mind appears to act on the body.

The biomedical model of medicine suggests every disease process can be

explained in terms of an underlying deviation from normal function such as
a virus, gene or developmental abnormality, or injury.

The biopsychosocialmodel (abbreviated "BPS") is a general model or

approach stating that biological, psychological (which involves thoughts,
emotions, behaviors(life style)and health beliefs), and social (socio-
economical, socio-environmental, family relationship and social support)
factors, all play a significant role in human functioning in the context of
disease or illness {Illness is the meaning for the patient`s life(feelings &
expressions); disease is the meaning in terms of pathology (diagnosis)}.

Studies proved that factors such as social isolation and stressful life events
are associated with higher mortality from all causes.

However, the biopsychosocial model is not just about causation but also
for patient care.

Tuberculosis as an example forbiopsychosocial model: tuberculosis is

defined as a disease of bodily organs following exposure to the tubercle
bacillus (biology), coughing, haemoptysis, weight loss and fever, treated
byanti-tubercular drugs (medical).

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But why other people exposed to the tubercle bacilli but not become
diseased, here appear the social factors where TB related to poverty,
overcrowding, under nutrition and low socioeconomic state,
psychologically: refuse immunization(thoughts&beliefs), HIV positive(life
style), treatment behavior (noncompliance to treatment).

The family physicians are the first to discover the weakness in the old
biomedical approach. As a large proportion of ill people seen in family
practice cannot be assigned to a disease category based on a physiological
or anatomical abnormality. For example: studies showed that only 50% of
patients presented with chest pain have specific diagnosis, 27% of patients
with headache and only 21% of patients with abdominal pain presented to
family practice have specific diagnosis.

Patient centered clinical method versus physicians centered clinical

method

In physicians centered clinical method: the physician is the leader of the

interview, physicians usually do not allow patients to complete their opening
statement of concerns in 69% of visits, interrupting patients after a mean
time of 18 seconds; information was sought almost completely through
theuse of closed-ended questions.Once interrupted, fewer than 2% of
patients went on tocomplete their statements. Collecteddata from physicians
centered approach are thus very much physician-determined, skewed toward
problems that are biomedical in natureand directed away from the
psychosocial aspects.

Patient centered clinical method is the way to practice biopsychosocial

approach with your patients and shift the clinical methods from treating the
disease to healing the whole patient (distinguish illness from disease
andcaring from curing).

Patient centered clinical method: means understanding the patient and

what the illness means to the patient.

A top priority in patient centered interviewing, therefore, is understanding

the patient's concerns (symptoms, fears, andideas). Using open-ended

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questions, the interviewer actively facilitates the patient's expression of
concerns.

In patient-centered approach the patient generates ideas and controlsthe

direction of the conversation. The physician follows the patient and not the
opposite.

In an ideal interview integrating the patientcenteredand physician-centered

approaches, the patientleads in areas where he or she is the expert (on
symptoms, concerns, preferences, and values) and then thephysician leads in
his or her area of expertise (detailsof organic disease and estimating
probabilities of disease).

Example 1: A woman's complaint of "chestpain" a patient-centeredresponse

might be, 'Tell me more about that."The response is patient-centered because
it follows thepatient's lead and adds no new idea to the conversation.A
physician-centered response to the same questionmight be, "Does it make
you short of breath?" Thisresponse is physician-centered because it adds an
ideaof interest to the physician (shortness of breath) that thepatient had not
previously introduced. The physicianhas taken the lead away from the
patient and established a new direction.

Example 2:"the day after my husband lost hisjob, my ankles got swollen
and my fever went to…………..”

Suggested responses are "Lost his job?" (Psychosocial) and "Ankles were
swollen?" (Biomedical).

Advantage of patient centered method:

1- Enhance patient satisfaction that reduces the malpractice of “doctor-

shopping".
2- Improve patient`s adherence to management plane (better blood
pressure and diabetic control).
3- More accepting of preventive strategies (for example, beginning a
tobacco cessation program).
4- Has a positive impact on health care utilization costs

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Practicing Patient-centered Interview:

1. Using the patient's name and introducingyour-self.

2. Starts with an open-ended questionor statement such as "How are
things?" “What have you come to see me about, today?”
3. As long as the patient begins talking, the physician must say
nothing or little for the first 30 seconds or so.
4. Use of specific open-ended questions ("Tell me more."; "Go
on.") Facilitate the free flow of information from and about the
patient. This period helps establishthat the interviewer is interested
and will listen.
5. Looking for other symptoms or problems can be screened by use
of this question: “So you say you’ve been getting chest pain. Have
you noticed anything else?” or is there anything else that you
would like to discuss today?!!”
6. Physicians need to explore the emotions and feelings of the
patients toward the problem by using of open ended questions as
“"How does that makeyou feel?")."That's a lot to happen in just
5 weeks. How's that affected you personally?"
7. If interrupting is necessary becauseof a failure to understand, it is
explained with astatement such as, "Excuse me, I didn't quite
followthat”.
8. Closed-ended questioning can be used for purposes (in later parts
of the interview) of clarification after the patient has establishedthe
focus (for example, "When did all this occur?").

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