風蕭蕭_Frank
以文會友
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.
需要新的醫學模型-對生物醫學的挑戰
〔美〕恩格爾 黎風 摘譯
http://blog.sciencenet.cn/blog-738133-681633.html
作者為美國紐約羅徹斯特大學醫學院精神病學和醫學教授。
出處：Engel GL: The need for a new medical model: a challenge forbiomedicine. Science 1977;196:129–136
引用：L 恩格爾.需要新的醫學模型:對生物醫學的挑戰[J].醫學與哲學,1980 ,1 (3) :88.
生物醫學模型
今天占統洽地位的疾病模型是生物醫學模型，分子生物學是它的基本學科。這種模型認為疾病完全可以用偏離正常的可測量的生物學（軀體）變量來說明。
在它的框架內沒有給病的社會、心理和行為方麵留下餘地。生物醫學模型不僅要求把疾病視為獨立於社會行為的實體, 而且要求根據軀體（生化或神經生理）過程的紊亂來解釋行為的障礙。因此, 生物醫學模型既包括還原論, 即最終從簡單的基本的原理中推導出複雜現象的哲學觀點, 又包括心身二元論, 即把精神的東西同身體的東西分開的學說。在這裏還原論的基本原理是物理主義原理, 即它認為化學和物理學的語言最終足以解釋生物學現象。從還原論觀點看, 表征和研究生物學係統的唯一概念工具和實驗工具本質上是物理學的。
在我們的文化中, 早在醫生們開始受職業教育以前, 他們的態度和信仰係統就受到生物醫學模型的影響。因此這種模型已成為一種文化上的至上命令, 它的局限性易受忽視。簡言之,它現在已獲得教條的地位。
在科學中, 當一個模型不能適宜地解釋所有資料時, 就要修改或擯棄這個模型。而教條則要求不一致的資料勉強適應模型或對這些資料幹脆排斥不管。生物醫學教條要求包括“精神病”在內的所有疾病用物理機製的紊亂來理解。
結果隻有兩種辦法才能把疾病和行為調和起來：一種是還原論的辦法, 它說疾病的一切行為現象必須用物理化學原理來理解, 另一種是排外主義的辦法, 它說任何不能作如此解釋的必須從疾病範疇中排除出去。在醫生和精神病學家中,還原論者和排外主義者鄙視那些敢於向生物醫學模型的終極真理提出疑問和主張建立一個更有用的模型的人為異端。
還原論生物醫學模型的曆史根源
為什麽還原論的、二元論的生物醫學模型在西方發展起來？拉斯莫森認為原因之一是當年基督教會準許解剖人體時仍堅持把身體視為靈魂從這個世界轉移到另一世界的容器的觀點。當時準許解剖人體有一個君子協定, 不許對人的精神和行為進行科學研究, 因為教會認為人的精神和行為與宗教和靈魂更有關係, 因而是屬於它的領域。這種協定對科學的西方醫學終於建立於其上的解剖和結構基礎有很大影響。
同時, 由伽利略、牛頓和笛卡兒闡明的科學基本原理是分析的, 意即研究的實體應被分解為可分離的因果鏈條或單元, 因此認為無論是在物質上和概念上整體可通過重組部分來理解。
隨著心身二元論在教會認可下牢固地樹立起來, 古典科學推進了這樣一些觀念：身體是機器, 疾病是機器故障的結果, 醫生的任務是修理機器。因此對疾病的科學研究方法一開始就用部分、分析法集中於生物學（軀體）的過程, 而忽視行為和心理學的過程。許多醫生的實踐就是如此。至少在20世紀初以前, 即使他們認為情緒對疾病的發展和進程很重要。對疾病的生物醫學研究法取得了意料之外的成功, 但也付出了代價, 因為它造成了許多問題。
生物醫學模型的局限性
我們現在麵臨這樣一種需要和挑戰：擴充對疾病的研究方法, 把心理學的研究方法也包括進去, 同時不犧牲生物醫學研究方法的巨大優點。
凱蒂把糖尿病和精神分裂症作為軀體病和精神病的範例加以比較。“這兩種疼病都是一組症狀或綜合征, 一個用驅體的和生化的異常來描述, 另一個用心理的異常來描述。每一種疾病都有許多病因, 強度範圍從嚴重致虛弱到潛伏或難以確定。也有證據表明在這兩種疚病的發展中遺傳的和環境的作用都起作用。”至少用還原論術語作描述時, 糖尿病的科學表征更為先進：它已從症狀的行為結構進展到生化異常的行為結構。
歸根到底, 還原論認為精神分裂症也要這樣解決。凱蒂說他不認為在精神分裂症中現在已知存在的（或將來可被發現的）遺傳因素和生物學過程在病因學中是唯一重要的影響。
他堅持認為同樣重要的是要闡明“經驗因素及其與生物學易感性的相互作用”如何成為可能, 或如何預防精神分裂症的發展。
對新的醫學模型的要求
（1）在生物醫學模型中, 特異性生化偏差一般被認為是疾病的特異性診斷標準。然而根據人生病的經驗, 實驗室檢查結果也許僅表明有潛在的疾病, 那時實際上沒有病。異常是存在的, 但病人沒有病。因此糖尿病或精神分裂症生化缺陷的存在充其量規定了人類生病的一個必要條件，而不是一個充分條件。更確切地說，生化缺陷隻不過是許多因素中間的一個, 生病是這許多因素的相互作用達到頂點所致。生化缺陷也不能用來說明病的一切, 因為完全的理解還要求其他的概念和參考係。因此糖尿病的診斷首先由某些核心的臨床表現（如多尿、多飲、多食、體重喪失等）提示的, 然後為實驗室檢查出胰島素相對缺乏所證實, 但這些如何被某個人經驗到、報告出來, 這些如何影響他, 這一切要求心理學、社會和文化因素的考慮。
（2）在特殊的生化過程與病的臨床資料之間建立一種聯係, 要求用科學上合理的方法來研究行為和心理社會資料, 因為這些資料是病人用來報告大多數臨床現象的術語。生物醫學模型忽視病人的口述, 主要依靠技術程序和實驗室測定。臨床資料和實驗資料之間相關的考查不僅要求有收集臨床資料的可靠方法, 高水平的問診技能, 而且要求對病人如何把疾病的症狀聯係起來的心理學、社會和文化決定因素有基本理解。例如許多口頭的表達導源於生活早期的體驗, 因此病人用來報告症狀的語言是十分含糊的。
（3）糖尿病和精神分裂症有個共同點：生活條件是影響疾病發作時間以及病程變化的重要變量。
對生活變化的心理生理反應可與現存的軀體因素相互作用以改變易感性, 從而影響疾病發作時間、嚴重程度和進程。
（4）決定具有糖尿病和精神分裂症生化異常的人是否和何時認為自己或被別人認為是病人, 心理和社會因素在其中也是關鍵性的。生化缺陷可決定疾病的某些特征, 但並不一定決定該人成為病人或處於病人地位。
（5）僅僅針對生化異常的“合理治療”不一定使病人恢複健康, 即使異常已得到糾正或改善。顯然生化異常的糾正和治療結局之間的這種差異是由於心理和社會變量所致。
（6）即使是應用合理治療，醫生的行為和病人與醫生之間的關係也有力地影響治療結局，或更好一些，或更壞一些。例如糖尿病人對胰島素的需要量變化很大, 隨病人對他與醫生的關係如何感覺而異。
生物心理社會模型的優點
為了理解疾病的決定因素以及到達合理的治療和衛生保健模式, 醫學模型必須也考慮到病人, 病人在其中生活的環境以及由社會設計來對付病的破壞作用的補充係統, 即醫生的作用和衛生保健製度。這就要求一種生物心理社會模型。
傳統的生物醫學觀點認為生物學指標是決定疾病的最終標準, 會導致目前的矛盾：某些人實驗室檢查結果是陽性, 說他們需要治療, 而事實上他們感到很好, 而感到有病的人卻說他們沒有病。生物心理社會模型包括病人和病, 也包括環境。對於一個焦慮不安和機能障礙的病人, 醫生必須考慮社會和心理因素以及生物學因素所起的相對作用, 這些因素既包含在病人的焦慮不安和機能障礙中, 也包含在病人決定是否承認自己是病人和是否承擔在治療中有合作的責任之中。
對醫學和精神病學都是挑戰
生物心理社會醫學模型的提出對醫學和精神病學都是一個挑戰。因為盡管生物醫學的成就巨大, 在公眾以及醫生中, 尤其是年青一代中對保健的需要不能滿足, 生物醫學對人類的影響不大日益感到不安。通常把這種情況歸因於現存衛生製度不適宜。醫學機構被認為是冷酷的和不近人情的。作為生物醫學中心的這些機構威望越高，這種抱怨越多。許多醫生的生物醫學基礎知識很好, 但醫治病人必不可少的品質很差。許多人承認單單在生物醫學模型範圍內這些是不能改善的。
霍夫曼把不必要的住院、濫用藥物、過多的手術和不適當的使用診斷試驗直接歸因於生物醫學還原論和它的支持者對衛生保健係統的統治。不自覺地讚成生物醫學模型並分裂為還原論者和排外主義者兩個陣營的精神病學家不認識精神病學是醫學中主要研究人及其條件的唯一臨床學科。過去30年對更為整合和整體的健康和疾病概念的表述, 主要是由利用起源於精神病學的概念和方法的醫生提出的, 尤其是弗洛伊德的心理動力學方法和心理分析, 以及梅耶的生活應激反應方法和心理生物學。他們的貢獻是提供了一個把心理過程包括在疾病概念內的參考係。心身醫學——這個術語本身是二元論的殘餘——成為跨越醫學兩個平行的、獨立的思想體係（生物學的和心理社會的）之間鴻溝的中介。
一般係統理論觀點
使心理社會的東西和生物學中的東西在醫學中和諧一致的鬥爭, 與受分子生物學的還原論方法統治的生物學有類似之處。生物學家中有人主張既要發展生命過程的還原論解釋, 也要發展生命過程的整體論解釋,既要回答“如何”的問題, 也要回答“為什麽”的問題。
貝特朗斐為了開辟整體論研究法的道路, 提出了一般係統理論。這種方法把一組有關的事件綜合起來看作是表現整體水平的功能和性質的係統, 這就有可能通過不同組織的層次,如分子、細胞、器官、機體、人、家庭、社會或生物圈來認識同形性。
從這些同形性中可以提出在各組織層次共同起作用和基本定律和原理。因為係統理論認為所有的組織層次在等級係統關係中是相互聯係的, 因此一個層次中的變化就會影響另一層次的變化, 采納係統理論作為科學方法將會大大緩和整體論和還原論的分裂, 促進科學學科間的滲透。對於醫學, 係統理論提供了一個不僅適合於疾病的生物心理社會的概念, 而且適合於把疾病和醫療保健作為相互關聯的過程來研究的概念方法。當一般係統方法成為未來醫生和醫學科學家基本的科學和哲學教育時, 可以預期對疾病的生物心理社會觀點就更易容納了。生物心理社會模型為研究、教學結構和衛生保健的行動計劃提供了一個藍圖。
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.
