Beyond the Biopsychosocial Model New Approaches to Doctor-Patient Interactions

Results

Preliminary Interview

In the initial interview, Dr M held that type 2 diabetes in Native Americans had complex biological, psychological, and social causes Table 2. She emphasized that “as a family practitioner, my outlook is that of a generalist, so I like to look at as many levels as I can, because I think that is what being a generalist is about.” She viewed quality communication as central to multilevel care and saw herself as introducing metaphors into the way patients thought about their bodies to “get them to understand [diabetes] the way” she understood the disease. This approach involved translating her biopsychosocial model of type 2 diabetes into the patient’s language to explain how diet, exercise, medication, and glucose monitoring were key self-care behaviors. She considered her strategy successful if her patients “said they would do these things, and they actually did them.”

Initial Interpretive Sessions

During the IPR and ID sessions, Dr M discussed an array of problems with misunderstanding and distrust in her patient interactions. Although the interactions were problematic for all of the study patients, what varied between patients was the intensity and significance of the misunderstanding or mistrust Table 3.* Dr M talked about feeling manipulated, disbelieving statements, distrusting information, despairing over differences, and even detaching from any expectation of helping a patient she could never trust. She considered her approach constrained by basic value differences with her patients, believing that for many health was not a high priority. This value difference, combined with her perception of fatalism in her patients, caused her to believe it unlikely that she could convince them of the value of her approach. This created a central conflict, because she thought her approach would not work unless her patients accepted its value. Thus, Dr M concluded that she needed to change her patients’ values about their health. However, she did not know how to change their values, and she did not know if value change was possible. In one of our final interviews she concluded, “They [the 9 patients in this study] are over there. I’m over here. I feel this absence, this nothingness between us that I don’t know how to bridge.”

Reframing the Research Problem

Although it is not surprising that a white physician and Native American patients would have difficulties communicating with each other, what was unexpected was that misunderstanding and mistrust would be problematic between this physician and these patients. Characteristics of both the patients and the physician selected for this study made it much more likely that gaps in communication could be bridged. The patients were all bicultural and fluent in English. The study was situated in an urban environment, decreasing the likelihood of a more unified cultural understanding that might be present in an isolated rural Native American community.²⁶ Dr M was aware of potential problems in communication with patients from different cultural and class backgrounds. She spoke of carefully translating medical information into the language of the patient and was knowledgeable about historical and political aspects of relations between Native Americans and whites and their relevance to the care of patients in her practice. The problems of mistrust and misunderstanding that emerged in this setting required further interpretation of the way Dr M’s knowledge of person, disease, and clinical context were interrelated and in the background during her patient interactions.

Knowledge of Patients

Dr M perceived that knowing patients well was “the single greatest thing” in her interactions with them. “I really have a lot of trust that my patients will red-flag those problems that are serious. I don’t have that with all my patients, but if I know a patient well, then I’ll trust that he won’t let it go if it’s important.” “Knowing a person” and “trusting a person” was not a conscious aspect of her decision-making process but an awareness that framed her stance toward each interaction. Dr M interpreted a patient’s story out of her own constructed story about the patient. Her interaction with Patient C is presented in this paper, but she had a story to tell about every patient involved in this study Table 4.

Knowledge of Disease

Dr M’s multilevel understanding of diabetes produced tensions in her clinical practice. These are exemplified in her views of the relationship between stress and diabetes care Table 4. In any given interaction, she needed to make decisions about what aspects of the disease required focus. Dr M developed an approach for determining what was important in particular situations. By “knowing a patient well from a medical perspective” she felt that she could very quickly assess what needed attention. This often meant directing the patient away from problems like stress and toward issues like exercise, diet, and medications, which were “the cornerstones of diabetic care” for Dr M. In this manner, she focused on the aspects of the disease she thought she could affect.