In a rigorously conducted qualitative study in this issue of the Journal, Robert Bartz1 provides a glimpse into the practice of a family physician caring predominantly for urban Native Americans. We read the physician’s thoughts about treating some of her patients with diabetes, and in one case we learn the parallel thoughts of the patient. The study, limited as it admittedly is, gives us much to ponder as we face the challenges of teaching and practicing culturally sensitive and culturally competent medical care.2
In his abstract, Bartz states that “biopsychosocial models of disease may conflict with patient-centered approaches to communication.” I would propose instead that the 2 models are somewhat different in focus and ought to be viewed as complementary.
The biopsychosocial (BPS) model was originally proposed as a scientific paradigm3 and as such, aims to be ethically neutral to the extent that any scientific model or theory can be. The BPS model teaches us that if we want to understand diabetes among Native Americans, we need to understand the social and cultural environment and the psychological impact that environment has on the individual, just as much as we would need to study the genetics and the biochemistry of the disorder in that population. This model goes on to suggest that in caring for any patient with diabetes, we ought to inquire into the psychological, social, and cultural factors in that person’s life, as well as examine the retina and monitor glycohemoglobin levels.
The BPS model, as a scientific paradigm, speaks peripherally to the issue of physician-patient communication, but solely in instrumental fashion, similar to the utilitarian approach that Bartz’s physician, Dr M, seems to adopt. That is, since science begins with accurate observation, scientific medical practice must begin with an accurate and thorough history. But the patient will, as a rule, provide a detailed, thoughtful, and accurate history only when the physician enters into an open, interested, and facilitative relationship with the patient. That sort of communication becomes a critical scientific tool, without which medical work could proceed no further.4
Various patient-centered methods, such as the model of sustained partnership, constitute different model types.5,6 Unlike the BPS model, they include both scientific and ethical aspects, and claim to help integrate those 2 elements of good medical practice. In an extreme case, a physician could use the BPS model as a superior way to manipulate or coerce patients, since knowing more about the patients’ emotions, cultures, and so on could render them more vulnerable to the physician’s machinations. The patient-centered models suggest that the physician ought to use this integrated knowledge of the patient as a whole person within a particular ethical framework that respects the patient’s basic rights and dignity, and takes very seriously the patient’s own life goals and projects.
One physician’s approach
How does Dr M stack up in relation to these various models? I ask this question not to criticize Dr M, who deserves great praise for having dedicated her career to the care of an underserved population and for trying hard to understand the lives of her patients. But Dr M may serve as an exemplary representative of a physician who does things that all of us do in our own practices, even when caring for patients of similar cultural backgrounds, so the analysis of her methods may be of general benefit.
First, it is worth noting that while Bartz describes Dr M as having a “sophisticated biopsychosocial approach,” her own description shows at least one way that this is not true. Many of her patients came to her wanting to talk about stress, and Dr M agreed that under the BPS model there was a direct relationship between emotional stress and the course of diabetes. But then her “medical perspective” caused her to “[direct] the patient away from problems like stress and toward issues like exercise, diet, and medications.” If the result was a group of patients with well-controlled diabetes, no one could criticize Dr M’s strategy. But she admitted that too often the result was a series of time-consuming repeat visits with the patient being no more compliant with the medical regimen at the end than he or she had been at the start. Apparently Dr M never asked herself whether talking to her patients more about stress and less about diet, exercise, and pills would actually in the end have been a more efficient way to secure their sympathetic cooperation and their compliance.
Turning next to patient-centered care, Dr M’s most important deviance from ideal practice seems to be what Bartz describes as her adoption of an instrumental rather than a dialogic mode of discourse. This is illustrated best in Table 5, a transcript of an encounter with Patient C. Patient C has just given Dr M a gift: She has admitted openly that she has never taken any of the oral medication for diabetes that Dr M prescribed. Admittedly, most of us do not especially enjoy receiving this type of information from our patients and are at least momentarily at a loss for words when it happens, but it is a gift nonetheless. It usually takes patients a lot of courage to admit this, and the disclosure often signals a heightened level of trust in the relationship on the patient’s side. If the physician responds appropriately, she may learn critical new facts about the patient’s belief system, and a much more effective and collaborative treatment plan may then emerge.