Beyond the Biopsychosocial Model New Approaches to Doctor-Patient Interactions
Recent use of direct observation of family physicians has provided a more thorough knowledge of “the black box” of community-based practice.34,35 This paper seeks to add to that literature by offering an in-depth multimethod qualitative approach for studying physician-patient interactions. Techniques using pre- and postencounter rating instruments cannot grasp what actually happens in interactions. Quantitative content or process analysis of physician-patient interactions cannot fully address the relationship between context and meaning in these interactions.36-39 However, the depth of meaning and context provided by qualitative studies in general and discourse analysis in particular are frequently dismissed because of concerns about generalizability.40,41
Critics might argue that the findings from this study derive from the practice of an uncaring physician and should not be generalized to the theoretical and practice issues drawn in the analysis. The evidence points in the opposite direction in regard to the integrity of Dr M. Although mistrust and misunderstanding were important issues to explore in Dr M’s interactions with patients, this was not immediately apparent from the content of the interactions themselves. This study required Dr M’s honesty and willingness to engage in the difficult process of disclosure and self-reflection over a busy 1-year period of clinical practice.
Limitations
Sampling strategies were used to address the generic critique of generalizing from a single case. The practice site was chosen to be exemplary of a community health center in a challenging low-income, urban, cross-cultural setting. The physician was selected to be an exemplary representative of a community-based clinician, and the patients were recruited to provide a sample of Native American adults with diabetes with varying degrees of social and cultural differences from the physician. If problems of distrust and misunderstanding exist in this setting, then similar patterns are likely to exist in other low-income cross-cultural contexts. Finally, this form of qualitative research allows the reader to judge the relevance of the findings to their own context.42 Are the problems Dr M described in her interactions with these patients understandable? Physicians may ask themselves: Am I getting through to this patient? Is this patient manipulating me? Is this patient telling the truth about their adherence to the regimen I have recommended? Do I have anything to offer this patient? Is there an unbridgeable gap in communication, or has the approach taken toward care of this patient been narrowed by an instrumental understanding of the person, the disease, and the context of care?
The organization of practice and the underlying structure of knowledge construction and use can create conflicts between the intentions of physicians and their actions in clinical practice.43-45 To understand and meet this challenge, we need further research of community-based physician-patient interactions that brings together theoretical and empirical forms of inquiry. Theoretical models, derived from ethics and the philosophy of medicine, seldom incorporate practice-based empirical study, while empirical work on physician-patient interactions frequently demonstrates a very limited attention to important theoretical concerns.46-49 Study of patient-specific narratives can bring together literature on biopsychosocial models, physician-patient interactions, patient illness narratives, physician self-awareness, and the organization of primary care practice. Further qualitative research should examine the way patient-specific narratives are developed by physicians practicing in different clinical environments and explore the interrelationships between patient-specific narratives and the content and quality of physician-patient interactions.
Conclusions
To apply biopsychosocial disease models in practice, physicians construct stories about patients as persons. These patient-specific narratives may be opened up or constrained by clinical context, and they both frame and are framed by physicians’ approaches to disease in particular interactions. To advance our use of integrated disease models, we need further study of the way patient-specific narratives are constructed in clinical practice. Application of integrated models of disease and construction of stories about patients may involve problems of misunderstanding and mistrust by either the patient or physician. The presence of these factors does not necessarily close off the possibility of meaningful and effective physician-patient interactions. The challenge is to strive to recognize misunderstanding and mistrust and to develop new strategies for reconstructing problematic interactions in community-based family practice.
Acknowledgments
The fieldwork for this study was conducted while Dr Bartz was a fellow in the Clinical Scholars program at Stanford University, with funding from the Robert Wood Johnson Foundation.
Dr Bartz gratefully acknowledges Richard Addison, PhD, Benjamin Crabtree, PhD, and Halsted Holman, MD, for advice on the initial design and implementation of this research; and Suzanne Fleischman, PhD; William Miller, MD, MA; Jessica Muller, PhD; and Guenter Risse, MD, PhD, for their thoughtful feedback and comments on earlier drafts of this paper.
