biopsychosocial model in education 01

8/7/2019 biopsychosocial model in education 01

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The Biopsychosocial Model in Education:DiscussionROBERT LAWRENCE, MD

Although I have observed Dr. Engel atwork and have read his papers, I havenever actually had the privilege of meet-ing and talking with h im. D uring a visit todiscuss a job opportunity at Rochester 7years ago, I was taken by Paul Griner tostand in the back of an auditorium toobserve, "George Engel interview a pa-tient." T hat was a very special experience.It was also a typica l exam ple of the esteemthat his colleagues at Rochester andaround the count ry have for h im.No wh ere else have I heard of the local starin action being used as part of the recruit-ing effort. W hen I was asked to particip atein this discussion and when the role that Iwas to fulfill was explained to me, I im-mediately conjured up the image of ajudge at a diving contest. The three speak-ers this morning had a degree of difficultyof 2.5, and w e, the judges, shou ld all flashcards reading 10, 10, 10.I would like to comment very briefly onsome thoughts that were stimulated byeach of the three speakers. Dr. Romanodiscussed the mutuality of experiencewith students informing the teacher. Inmy own attempts to observe my personalgrowth and development I have been in-trigued by the writings of George Vaillantand others about psychologic develop-

From the Division of Primary Care and FamilyMedicine, Harvard Medical School, Boston, Mas-sachusetts.Address requests for reprints to: Dr. Robert Lawr-ence, Director, Primary Care and Family Medicine,Harvard Medical School, 25 Shattuck Street, Boston,MA 02115.

ment during the twenties, when most ofour students are in medical school andhouse officer training. At a time whenthey are supposed to learn how to loveand to form intimate relationships, we putthem in a very harsh environment; it is asthough we were to suggest a romanticinterlude with a member of the oppositesex but instead of providing a nicewooded bower we put them in the middleof Times Square or some other hostileplace. A real challenge for all of us inmedicine is to create a less harsh envi-ronment. The current educational settinghas certainly caused great stress in thestudents with whom I work at Harvard.Dr. Rom ano also comm ented on the factthat the students are quick to point outpsychiatry 's neglect of the poor, thechronically psychotic, the alcoholic, andso forth. That indictment is not restrictedto psychiatry, for students are equallyquick to point out the failings of the otherdisciplines. One of the unique attributesof prim ary care is that its practition ers end

up being the final common pathway fortheir patien ts. Robert C opeland, a practic-ing primary care internist in LaGrange,Georgia, once said about the realities ofpractice compared to his experience as ahouse officer:There is no change day in practice. When the30th of June comes, we can't sign off service notes,

turn over the hopelessly demanding patient, thedying patient, the bothersome patient, or any otherof our patients who continue to nettle us. We mustcontinue to live with those people and try to providethe support and therapy that they need.Psychosomatic M ed icine Vol. 42, No . 1:11 (Supplement 1980) 137


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EAT O N, SADLER, LAWRENCE

Dr. Romano's comments on daily liv-ing, the patient-client to penitent, re-m ind ed me that one of the things I had notanticipated when I chose a career in pri-mary care was that inevitably m any of mypatients would become friends. As theybecame friends I rather systematicallyseemed to eliminate from the differentialdiagnosis all of the "bad diseases," and Ibecame less of a doctor. It takes a veryconscious effort to continue to think thatthis patient to whom you have drawn veryclose and who is a very special person inyour life might in fact be presenting withthe symptoms of an early cancer or ofsome other "bad disease." The obverse isthe friend as patient. I have been asked ona number of occasions to take on as pa-tients friends of mine, and I am alwaysamb ivalent. On the one ha nd I'm flatteredthat they should single me out as theirphysician, while on the other hand I rec-ognize that immediately on assuming thatresponsibility I will have altered a veryimportant social relationship. I neverheard anything about these dilemmas inmedical school. I suspect that students atthe University of Rochester do hear aboutthese dilemmas of the doctor-patient rela-tionship about which Dr. Engel's writingsand Dr. Rom ano's here have shed so mu chlight.

When I was a neophyte a t tendingphysician at Chapel Hill, I saw a patientreferred from Charlotte to the G.I. groupfor evaluation of chronic abdominal pain.I began to interview her with the studentsand the house staff present. Very quicklyher intractable abdominal pain complaintwas replaced by a very tearful account ofher terrible marriage, her disappointmentin her children, and so forth. I was feelinga little smug as we walked out of theroom, waiting for the house staff and thestudents to say, "Well, isn't that marvel-

ous, here we're going to save her fromhaving to run her bowel and doing otherinvasive studies." Instead, one of the stu-dents turned to me and said, "Dr. Lawr-ence, have you always liked crocks?" At-tempts to apply the biopsychosocia lmodel involve a constant struggle, and Ifind it very easy to become discouragedwhen we encounter this kind of resis-tance. However, as I have observed thechanges in those around me and in my-self, the fundamental legitimacy and au-thenticity of the biopsychosocial model isbeing confirmed everyday.

Dr. Swisher described some of his con-cepts for the biopsychosocial model, ex-panding it to an environmental model. Dr.Weiss's daughter is in our primary careresidency pathway at Beth Israel, and she,along with the other residents, oftenchuckles a t my preoccupa t ion wi thseatbelt-wearing behavior among my pa-tients. I can imagine their reaction when Iadvocate vegetarian bicycl ing as theproper b iopsychosoc ia l -env i ronmenta lmodel of health care! In addition to BetsyWeiss and people like her, we still have agroup of house staff who, largely becauseof their own unresolved problems, arecompletely fixated on the biomedicalmodel. A new term has arisen at the BethIsrael this year to describe ordering aGallium scan, a brain scan, a liver-spleenscan, and various other kinds of scansnow the house staff just says,"Let's nukethe patient." When you are working in anenvironment where there are people whowant to "nuke" the patient while we at-tempt a very different pattern of delivery,conflict and disagreement are often in-evitable.Some of Dr. Weiss's comments about thedelivery of primary care reminded me ofthe importance of the covenant relation-ship between doctor and patient. We are,

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BIOPSYCHOSOCIAL MODEL IN EDUCATION: DISCUSSIONor should be, with our patients throughthick and thin; there is something thattranscends what is denoted by the termsclient and provider. Rashi Fein, a healtheconomist on the Harvard Medical Schoolfaculty, is deeply disturbed by the ten-dency to talk about providers and clientsrather than doctors and patients; this ten-dency demeans what is fundamentallyimportant about the role that we play inthe lives of our patients and the role theyplay in our lives.Patient expectations and physician be-havior conspire to reinforce the notion,"fix it." Duncan Newhouser's data onherniorrhaphies suggest that if every 70-year-old patient with a symptomatic her-nia were given a truss, we would notshorten that individual's life expectancy,but would in fact add one or two weekscompared with the life expectancy of pa-tients taken to surgery. The savings tosociety would be approximately $1200per patient with a symptomatic hernia.Duncan Newhouser's rather radical pro-posal was that we give a $1200 premiumto each patient in whom we diagnose asymptomatic, nonincarcerated inguinalhernia. The patient could use howevermuch of the $1200 he needed to get what-ever kind of truss he wanted. I am certainthat the market would soon be floodedwith all sorts of wonderful models.An NIMH work group report, comment-ing on the difficulty of teachingpsychiatry and psychiatric principles tomedical students and house officers,noted that understanding of behavioroften requires a greater exposure to theelements of biology. One reads anotherchapter in the biochemistry textbook, at-tends another conference, or looks at 10

more slides. In contrast, an understandingof psychiatry depends more on a deeperunderstanding of what is already knownby the student. The analogy that sprang tomind was the child's game of the pictureof the woods with an animal hidden initthe face made of leaves and twigs andso forth. If you didn't know what a mon-key looked like you would stare at thatpicture for hours and never see the mon-key, but if somebody told you what themonkey looked like and then pointed outthat this leaf corresponds to the right earand so forth, you would never again lookat that picture without immediately see-ing the monkey. I think a lot of psychiatryis like that, and people in different stagesin their medical training suddenly seemto see the monkey in the woods. One ofthe great conceptual challengesone thatDr. Engel has certainly taken steps towardmeetingis translating that remarkablecognitive and experiencial phenomenoninto a form more readily transmitted toour students.Regarding the role of primary care intreating a population that is encompas-sing ever larger numbers of the aged, Iwant to report that the Harvard MedicalSchool has just created a committee ongeriatrics chaired by a University ofRochester graduate. The committee isgoing to include psychiatrists, primarycare practitioners, faculty from the basicsciences and biology of aging, and facultyfrom the sociology and other social sci-ence departments of the University. Thiswill bring to our institution some of theinterdisciplinary approach to the bio-psychosocial model that has beenpioneered at Rochester.

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