Anthony L. Suchman

The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry

The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex—subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term “new paradigm” would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.

What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care

Physicians do not receive from the medical model the same explicit guidance in relating to their patients as in making diagnoses and prescribing pharmacologic and other treatments. To meet this need, we offer a framework for expanding the model. Therapeutic contact takes place within a connexional, or transpersonal, dimension of human experience, within which basic human needs for connection and meaning are met. Although seldom explicitly recognized, connexional experience is basic to medical care. Awareness of this dimension of experience leads clinicians to appreciate that establishing a therapeutic relationship is one of the principal goals of medical practice. It also reframes the doctors task to make clinical uncertainty more tolerable and situations in which there is no appropriate biomedical response (such as care of the terminally ill) less frustrating and more fulfilling.

A new theoretical foundation for relationship-centered care. Complex responsive processes of relating.

Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive processes of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC.

Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school.

The social environment or “informal” curriculum of a medical school profoundly influences students’ values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consistently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future.

The impact of a program in mindful communication on primary care physicians.

Purpose In addition to structural transformations, deeper changes are needed to enhance physicians’ sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians’ well-being and the care they provide. Method In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. Results Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. Conclusions Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

The Path to Professionalism: Cultivating Humanistic Values and Attitudes in Residency Training

Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician.

Diagnostic uses of the activated partial thromboplastin time and prothrombin time

The activated partial thromboplastin time (APTT) and prothrombin time (PT) have three principal uses. In screening for coagulation disorders (or increased risk of postoperative hemorrhage), the tests add no information to the preoperative care of patients without clinical findings indicative of increased bleeding risk. Furthermore, the prevalence of asymptomatic congenital coagulopathies is so low that false-positive test results greatly outnumber true-positive results. Thus, clinicians may use clinical assessment to screen and should reserve coagulation tests to investigate patients with abnormal findings. In evaluating abnormal bleeding, these tests are sufficiently sensitive that if both are negative, further investigation of the coagulation system is obviated. If one or both tests are positive, the pattern of results directs further attention to limited segments of the coagulation sequence. In monitoring anticoagulation therapy, the APTT and PT tests appear to contribute to the safety and effectiveness of heparin and warfarin therapies, respectively.

Does physician uncertainty affect patient satisfaction

Physicians may choose one of several strategies when initially uncertain about making a specific therapeutic recommendation. The authors investigated how patients’ satisfaction is affected by disclosure of uncertainty and its attempted resolution during a clinical encounter. Three hundred and four patients awaiting appointments at a university hospital’s ambulatory medical clinic were randomized to view one of five videotapes (VTs) of a patient seeking advice about antimicrobial prophylaxis for a heart murmur. In VT-1 and VT-2, the physician disclosed no uncertainty and prescribed therapy. In VT-3, VT-4, and VT-5, the physician openly conveyed uncertainty but then: (VT-3) prescribed antibiotics without resolving his uncertainty; (VT-4) consulted a reference book with the patient present, then prescribed; or (VT-5) checked a computer with the patient present, then prescribed. Patients rated their satisfaction with the physician on a standardized questionnaire. Differences in satisfaction between the five VTs were significant (p=0.001), with the highest ratings found for VT-1 and VT-2, where no uncertainty was disclosed. The lowest ratings in satisfaction were found when the physician expressed but then ignored uncertainty (VT-3) or examined a textbook (VT-4). Global satisfaction was inversely and significantly correlated (r=−0.47) with the patients’ perception of uncertainty in the physician. The manner in which clinical uncertainty is disclosed to patients and then resolved by the physician appears to affect patients’ satisfaction.

Enhancing the Informal Curriculum of a Medical School: A Case Study in Organizational Culture Change

BackgroundCalls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional “top–down” approaches to changing culture and relational patterns in organizations often disappoint.ObjectiveIn an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems.ApproachEmploying a strategy of “emergent design,” we began by gathering and presenting stories of IUSM’s culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories.ResultsThe vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students’ satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment.ConclusionsThis case study of emergent change in a medical school’s informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional “top–down” approaches to changing culture and relational patterns in organizations often disappoint. In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems. Employing a strategy of “emergent design,” we began by gathering and presenting stories of IUSM’s culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories. The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students’ satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment. This case study of emergent change in a medical school’s informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.

Classic conditioning and placebo effects in crossover studies

Objective: To find evidence of classically conditioned placebo effects in a placebo‐controlled crossover drug study. Specifically, we tested a prediction of the conditioning model that the placebo response will be greater after drug exposure than before.